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U.S. NAVY MEDICINE 



November-December 1983 




Surgeon General of the Navy 
VADM Lewis H. Seaton, MC. USN 

Commander 

Naval Medical Command 

RADM William M. McDermott, Jr., 

MC. USN 



Public Affairs Officer 
LT Drew Malcomb, USN 

Editor 

Jan Kenneth Herman 

Assistant Editor 
Virginia M. Novinski 

Editorial Assistant 

Nancy R. Keesee 



U.S. NAVY MEDICINE 



Vol. 74, No. 6 
November-December 1983 



I From the Commander 

Put the Lid on Fraud, Waste, and Abuse 

4 Department Rounds 

LHA Means "Largest Hospital Afloat" 
JOl G. Jochum. USN 

7 Features 

Managing an Effective Hazardous Substance Program at Sea 

HM2 T. Zimmerman, USN 

9 NAMRU-3's New Cairo Lab Open for Business 
LCDR W.R. Whuaker. USNR-R 

12 So You Want to Make Chief 
LCDR J. L. Peterson, MSC, USN 



POLtCY: V.S. Jhtf MrJUine ii an official puii^tcation oi ihe 
Nav> Medical Pcparimfm pyhli^hcd by \he Naval Medical 
Command It dj^seminaio U> Sus-x^ Medical l3cparCnK(it per- 
sonnel ofHcifll atid profftsiiirntl irlfonnaiion fclati*e ^o medi- 
cine, dcniism-. and the allied health vcicncei. Opinion* 
CAprcs^ed are thiKf oT t}ic iiuihon xtk] do not necessarily rcpre- 
urnl ibe nfficial pcmiian ot the Dcpanmeni of the Na%%, the 
Na\'al McdtcaJ CommiiiKl. or ans oihcr ^^emmemaJ depan- 
ment or agcncv*. Trade aanie:^ arc used ioi identiricatton ont\ 
and do not represent an endorsement (>y ihe Department of [he 
Navy or ihc Naval Medical Command. Although I'.S- .\iiv\ 
M^dtrinr m^v ciie or exiract ^rom <|irM.tnK. afficiiit auEhority 
for «lion should be obiamcd from the cued tcterence 

DISIRIBUTION IS Voiv ^eJtfine ti distffliuicd to 
active duty Medical Dep^nnteni pcnonnel vja the Standard 
Na^y Distfibmwn List. Tht Mloifcin^ dwlrrbuuon n author- 
ixed: one copy for each Medical. r>cmal. Mediciil Service, and 
Nur^iC Corp^ offictr: ortc aps for each tO enluied Medicdl 
Dcpartmeni tnember^. Ktquevis to mcfcas.e or dctrcaw the 
number of al fatted copies ihoyW he for*afded to V S^ Ami 
Meiikinr na th* local command 

LS .V^ t Y MEDiCISE n publi-ihtfd from a]>prapruicd 
funds- by authonn of Drpartment o* ihe Na^\. \aval Medtcal 
Command, in accordance with Navy Pubticauooa and Prtntmg 
Rc^ulalLons P05. Second class posia^ paid at Philadelphia, 
PA, and addhional mailmg offices. tSSN 0364+W(07 Anicics. 
letters, and address chan{^& miiy be forwarded lo the Editor 
t.S Sa\.} Meditmf. Departnu-m ot the Navy. Naval Medtcal 
Command (MEtK'OM 00D4J. Washington. DC 30372 Tele- 
phone { Area Code 2Q2i h5 J-l 237. dS J-i 297. .-Vutovon :<M- 1 :.17. 
394-1297. CDntribunon<> Irom the field are welcome and will bt 
published as space permits, subject to edituig and ptt&sible 
abridgment 

F^or ^le by the Superkmendtnt of Documents. (.LS, Govem- 
mcni Printing OfTscc. Wjishinjfton. DC 30402, 



NaVMED P-508* 



14 Reserve 

Fleet Medicine Revisited 20 Years After 
CAFTJ.B. Henry, MC USNR 

16 Clinical Notes 

Xerostomia: Diagnosis and Treatment 
COL J.L. Konzelman, DC, USA (Ret.) 
CDR G.T Terezhalm\\ DC. USN 

19 Professional 

Perinatal Death: Aiding Grief Resolution 
LCDR C.C, Coddington, MC. USN 

22 Changes in Factor VI 11 Activity, Antigen, and Ristocetin Cofactor 
Levels After Infusion of DDAVP 
LCDR A. S, Kirshenbaum, MC, USNR 
LCDR K.R. Fichman, MC, USNR 
CAPT H.M. Koenig, MC USN 

Notes and Announcements 

2 Farewell From HMCM Brown 

3 HMCM Green New Force Master Chief 

6 NAVMEDCOM Dedicates Medal of Honor Hall 

25 In Memoriam . . . F, Edward Hebert School of Medicine . . .Top 
Medical Reservist . . .Occupational Health Workshop , , , AOMA 
Publications List Available 

26 Ships Named for Hospital Corpsmen 

27 INDEX Vol. 74, Nos. 1-6, January-December 1983 



POSTMASTER: Send changt of address ordcnm U.S. Sav»l 
Publuralions and Forrm Ccmcr. ATTN: Code 306. J«OI Tabor 
Avenue pfailaddphia. PA I4I2Q 



COVER: The Medal of Honor is the highest military award for a deed 
of personal bravery or self-sacrifice above and beyond the call of duty. 
Recently, the Naval Medical Command dedicated the Medal of Honor 
Hall at its Washington, DC, headquarters and paid tribute to 2 1 hospi- 
tal corpsmen who earned this Nation's top military honor (see page 6). 



From the Commander 



Put the Lid on Fraud, 
Waste, and Abuse 



We have all been reading the horror 
stories both within and without the 
Navy concerning fraud, waste, and 
abuse. Metal screws that cost $119. 
Cotter pins that run SI 2 through the 
supply system, but SO. 1 5 at the local 
hardware store. Huge rebates being 
paid to the Navy by defense contrac- 
tors, but only after a whistleblower 
points out the waste. 

You get my point. We, as a respon- 
sible arm of the Navy Department, 
cannot and must not ever let a single 
instance of fraud, waste, or abuse go 
unnoticed. And if we notice it, we 
must deal with it. We can be satisfied 
with nothing less. 

Fraud, waste, and abuse can occur 
in many areas other than the standard 
purchasing agreements. Have you 
checked your official phone bill lately? 
Does someone in the command check 
it every month to see if unauthorized 
calls are being made? I hope so. 1 also 
hope that if such calls are found, the 
responsible party pays whatever fees 
are necessary to reimburse the Gov- 
ernment. Of course, that option only 
exists for the first infraction. If an 
offender makes the same mistake 
again, he must be dealt with severely. 

Does someone keep a watchful eye 
on overtime and compensatory time? 
It's another area fraught with abuse. 
Is the comptroller or purchasing agent 
careful always to exhaust official 
supply lines before going to the open 



market? Even though it can be a cum- 
bersome system, we must make use of 
it; there's no alternative. 

The list could, unfortunately, go on 
and on. The point is, we must be in the 
forefront of the war on fraud, waste, 
and abuse. Nothing less will suffice. 
Remember that every time someone 
abuses the system, our taxes pay the 
way. That's the bad news. 

The good news is that 1 can now 
make a strong pitch for our new fraud, 
waste, and abuse system in the Medi- 
cal Department. The program will be 
on line shortly and will include a toll- 
free phone number for reports of 
fraud, waste, and abuse. This is not a 
witch hunt, but 1 want to assure you 
that my efforts to eliminate any indi- 
cation of fraud are quite serious. I 
have very strong feelings about the 
topic. 

If anyone of you witness fraud, 
waste, or abuse, I consider it your duty 
to report the act on the hotline. Your 
confidentiality will be maintained in 
the strictest sense. We must, however, 
have some way of contacting you for 
foUowup details. For that reason, the 
recording you hear when you call the 
hotline will ask for your name and 
phone number. Please provide us with 
this vital information. Our system will 
be much more effective. 

The numbers are: nationwide, toll- 
free (800) 821-8137, and in the 
Washington metro area, 463-0275. 




Please use the system. It's our best 
defense against fraud, waste, and 
abuse. We will provide more informa- 
tion and publicity materials in the very 
near future. 

A major point; the hotline is 
designed to handle reports of fraud, 
waste, and abuse. We should not over- 
load it by allowing its use as a com- 
plaint line. We have other, similarly 
strong, avenues to address those 
matters. 



William M. McDermott/jr. 
RADM, MC, USN 



November-December 1983 



Farewell From 
HMCM Brown . . . 




HMCM Brown 



This last message is being written with 
mixed emotions and a heavy heart. 
Since 1 entered the hospital, 1 have had 
considerable time for thinking and can 
come to only one conclusion; the Navy 
Medical Department is the greatest 
and can only continue to improve. 

The years past have seen our corps 
faced with numerous obstacles during 
periods of peace and turmoil but our 
predecessors never faltered. Our herit- 
age is one of dedication, service to 
patients and country, and pride and 
professionalism in accomphshment. 
We have all witnessed major transi- 
tions in the Navy Medical Depart- 
ment. We will continue to see changes 
in the future and I would not be so 
foolhardy as to predict what they will 
be but I think we can all look to the 
future with the greatest confidence. 

The challenges of the new are no less 
frustrating and overwhelming. We are 
experiencing new and painful encoun- 
ters with detractors of our health care 
system but our members continue to 
demand and demonstrate a maturity 
and professional commitment rivaled 
by none. Never forget that everyday, 
the common denominator of every- 
thing we do is people. You have got to 
like people, all kinds of people. 

Compare the complexities of to- 
day's health care arena both within 
and without the Navy with that of just 
a few years ago. Who brought it 
about? Men and women with ability, 
with drive, and a commitment to mak- 
ing it better — changed the shape of 
their future and opened the doors for 



you and those who will come after. It 
has been people who made our 
system — any system — become a pro- 
ductive, dynamic instrument by which 
our goals have been met. I take great 
pride in your individual and collective 
accomplishments; the future of our 
Medical Department lies in your 
steady, capable, and compassionate 
hands. 

As 1 take my leave from being your 
Force Master Chief, 1 want each of 
you to know I will always value your 
friendship and support. I will never 
erase the great appreciation I have for 
all your efforts during this tour and 
the knowledge that you enjoy my 
upmost confidence. Always remem- 
ber, 1 loved every one of you. 

I know that you will give Master 
Chief Green[Louis V, Green, Jr.jyour 
full support. Without question, he is a 
great person, leader, and most of all, a 
Master Chief Hospital Corpsman that 
believes in you. 

Thank you and 

goodby. The Force 

has and always will be 

with you. 




EN W. BROWN 



P.S. 1 cannot begin to express my 
thanks and appreciation from all well- 
wishers. There is no greater therapy in 
this world than people. 



U.S. Navy Medicine 



. . . HMCM Green New 
Force Master Chief 



Master Chief Hospital Corpsman 
Louis V. Green, Jr., USN, a native of 
Pennsylvania, enlisted in the Navy in 
September 1954. After graduating 
from Hospital Corps School at the 
Naval Training Center, Bainbridge, 
MD, he served at the Naval Hospital 
and at Bancroft Hall Dispenisary, U.S. 
Naval Academy, both in Annapolis, 
MD. 

In 1957 HMCM Green reenJisted 
and reported to the National Naval 
Medical Center, Bethesda, MD, for 
X-ray technology training. He then 
served with Force Troops, Fleet 
Marine Force, Atlantic, based from 
Camp Lejeune, NC. Next came Medi- 
cal Equipment Repair School, where 
he graduated at the top of his class. He 
subsequently was assigned to the 
Naval Supply Depot, Mechanics burg, 
PA. 

After Advanced Hospital Corps 
School at Portsmouth, VA, Green 
reported to the Third Force Service 
Regiment, 3rd Marine Division, 
Okinawa, and spent a year in Viet- 
nam. Later assignments included 
USS DeLong (DE-684), homeported 
in New York City and a tour at the 
Naval Submarine Medical Center, 
Naval Submarine Base, Groton, CT. 

Upon his selection to Master Chief 
Hospital Corpsman in 1973, Green 



reported to the U.S. Marine Base, 
Twentynine Palms, CA. In 1976 he 
returned to the Naval Submarine 
Medical Center to serve as Command 
Master Chief. He served with the 
Marines again at 1st Marine Brigade, 
Kaneohe, HI, and then reported 
to the Naval Health Sciences Educa- 
tion and Training Command, Bethes- 
da, MD. Green was serving as 
Command Master Chief there when 
his selection as Force Master Chief, 
Naval Medical Command was an- 
nounced. 

HMCM Green holds an associate 
degree from Mohegan Community 
College, Norwich, CT, and a bache- 
lor's degree in health care services 
from Southern Illinois University. He 
is a student associate with the Ameri- 
can College of Hospital Administra- 
tors. 

His military awards include the 
Navy Commendation Medal, Navy 
Achievement Medal, Navy Unit Com- 
mendation, Good Conduct Medal 
(7th award). National Defense Medal, 
Vietnam Service Medal, Vietnam 
Meritorious Unit Commendation 
Gallantry Cross with Palm and 
Frame, Vietnam Meritorious Unit 
Commendation Civil Action 1st Class 
with Palm and Frame, and Vietnam 
Campaign Medal. 




HMCM Green 



November-December 1983 




Department Rounds 



LHA Means "Largest 
Hospital Afloat" 



Ask USS Tarawa's LT Tom Burden, 
what LHA stands for and he'll tell you 
"largest hospital afloat." 

The Medical Service Corps officer 
is not exaggerating. Filling a role for- 
merly performed by hospital ships, 
USS Tarawa and her class of ships 
reflect the Navy's efforts to consoli- 
date as many functions as possible 
within one hull. 

Tarawa is designed to fulfill the 
requirements of lour warships in 
one an assault ship, an amphibious 
transport dock, an attack cargo ship, 
and a dock landing ship. 

But it is her humanitarian role that 
earns her the distinction of being the 



largest hospital afloat. Her medical 
and dental facilities can accommodate 
up to 300 patients. With two main 
operating rooms, postoperating 
wards. X-ray rooms, lab pharmacy, 
blood bank, sterilizer room, physio- 
therapy room, and recuperative and 
isolation wards, the LHA has the 
Navy's most extensive medical facili- 
ties afloat. 

LCDR Mike Silverberg, the avia- 
tion medical officer aboard Tarawa 
explains why: "The differences be- 
tween ourselves and a carrier is that 
we carry more marines. We're close to 
the beach and would be the first 
echelon hospital beyond the beach. 





Hospital corpsmen William Healy (right} and Dennis Boyles administer shots to 
Tarawa '.s crew in the main triage area. Healy is assigned to the I si Marine Brigade from 
Marine Corps Air Station, Kaneohe, HI, but currently is embarked on Tarawa. 



Our secondary job (besides being an 
assault carrier) is to be an offshore 
hospital." 

According to LCDR Neil Fishbeck, 
Tarawa'^ dental officer, he may ex- 
amine anywhere from 4 to 20 patients 
a day. "Support ships such as tenders 
have more comprehensive dental pro- 
grams," he maintains. "We can elimi- 
nate infection and pain, but are not 
considered a primary definitive care 
dental facility." 

The logic behind this is that 
Tarawa's, primary role is in support of 
combat casualties. A visitor to the 
LHA's medical department is at once 
impressed with the main triage area, 
which serves as a receiving station for 
mass casualties during war. In peace- 
time, it is the area where patients line 
up for shots, shipboard divisions listen 
to medical lectures, and mass casualty 
drills are conducted. 

At the far end of the triage (which 
refers to sorting of patients according 
to the extent of their injuries) is an 
elevator that links the medical depart- 
ment with the night deck. Stretcher- 
bearers can transport casualties into 
the flight deck battle dressing station 
for immediate first aid. 

There are four smaller auxiliary sta- 
tions scattered throughout the ship. 
At the far end of the passageway is a 
12-bed morgue. 

But what sets the ship's facilities 
apart from all other fleet facilities is 



U.S. Navy Medicine 




USS Tarawa 



'^■'i'J^ 



Big is good hut empty is heller in Tarawa'.v 17-bed intensive c 
orpsmen Kevin Alexander (left) and David Huff are assigned to 



the 17-bed Intensive Care L^nit, just 
off the 40-bed main ward. This is 
the pride of the medical department, 
and as Silverberg guides you for a 
closer look, his voice cannot camou- 
flage his excitement. 

"Each bed has wall suction and oxy- 
gen, a cardiac monitor, a Schwann 
Ganz catheter" (unit that measures patients. 
heart pressure), he says. In addition. 
the unit has facilities for burn patients, 
severe trauma patients, and can render 
surgical, orthopedic, and cardiac care. 

When the ship's surgical team is 
embarked. Tarawa often reaches out 
to help others. "When an LHA goes 
into certain ports," explains Silver- 
berg, "they'll set up clinics on shore 
with supplies. In one Indian Ocean 
port, USS Betleau Wood treated tra- 
choma, malnutrition, leprosy, tuber- 
culosis, and parasite infections — all 
tropical diseases. An LHA probably 
has better medical facilities than some 
Third World countries." 

This ability to render assistance to 
others is best demonstrated by a con- 
tinuing phenomenon —treating boat 
people that the ship sometimes takes 
aboard, "On the last LHA we were 
aboard, "says Silverberg. wepicked up 
70 boat people, some seriously ill. "We 
resuscitated people, and pulled one 
pregnant, dehydrated woman out of a 
coma. We even carry diapers and baby i,i,er stands minui litters are lined up in 
food." □ Tarawa '.V main triage area during a mass 

SiiiiA ;iikI photos b> .lOI tilciiii .locluim casually drill. 




are facility. Hospital 
monitor treatment of 




NovcmtiLT-I^ecembci 1^8.1 



NAVMEDCOM Dedicates 
Medal of Honor Hall 



The Naval Medical Command, in 
ceremonies on 21 Nov 1983. dedi- 
cated a Medal of Honor Hall in 
memory of 21 hospital corpsmen 
who have received the prestigious 
Medal of Honor. The Hall is 
located in the original Naval Ob- 
servatory at the Naval Medical 
Command Headquarters in 
Washington, DC. 

To create the memorial, a confer- 
ence room was refurbished and 
hung with photographs of each 
honoree and a copy of the original 
citation which accompanied their 
awards. An actual Medal of Honor 
is also prominently displayed. 
Eleven of the plaques contain a ship 
photograph, testament to the 
number of Navy ships named in 
honor of hospital corpsmen. 

Representing the Chief of Naval 
Operations was guest speaker 
RADM John D. Bulkeley, USN 
(Ret.), a Medal of Honor recipient. 
The ceremony was attended by 
Navy Surgeon General, VADM 
Lewis H. Seaton, MC, and Com- 
mander, Naval Medical Com- 
mand, RADM William M. 
McDermott, .Ir., MC. Also present 
were MGEN Harold G. Glasgow, 
USMC; Master Chief of the Navy, 
Billy C. Sanders; Sergeant Major 
of the Marine Corps, Robert E. 
Cleary; and Force Master Chiefs 
from most Washington based 
commands. 

RADM Bulkeley was awarded 
the Medal of Honor for his Philip- 
pine service as Commander of 
Motor Torpedo Boat Squadron 3. 
Asked to describe the basic attrib- 
utes of a Medal of Honor recipient. 



he said simply, 'There really is no 
common denominator of such peo- 
ple. It has to do with an inner spirit 
— a determination." 

MGEN Glasgow, who repre- 
sented the Commandant of the 
Marine Corps, said, 'The Navy's 
hospital corpsmen, throughout his- 
tory, have provided splendid sup- 
port for the Marine Corps. They 
are such a part of us that the unique 
relationship between the Corps and 
our corpsmen is often taken for 
granted. But they have been with us 
— at Tarawa, at Iwo Jima, in Beirut 
and Grenada, and always. 

"A marine might have to worry 
about a lot of things when he's in 
the field," said GEN Glasgow, "but 
he never has to worry about his 
'doc' All he has to do is look over 
his shoulder, in the thick of the 
fighting, and there's Doc, risking 
his life to save another marine. 
When the last Taps is played, you 
will still hear the echo of a marine 
calling for his doc, They're closer 
than brothers." 

The Medal of Honor Hall was a 
project of former Medical Depart- 
ment Force Master Chief HMCM 
Stephen W. Brown. In ceremonies 
just prior to the dedication, he 
turned over duties as Force Master 
Chief to HMCM Louis V. Green. 
Jr. 

A total of 2! hospital corpsmen 
have been awarded the Medal of 
Honor. The first was Hospital 
Apprentice Robert H. Stanley, for 
service during the China Boxer 
Rebellion in 1900. The last. Hospi- 
tal Corpsman Second Class David 
R. Ray, was awarded a posthu- 



HM2 Oltin Raimiis!en 




RA DM Bulkeley, guest speaker for the 
Medal of Honor ceremony, addresses 
the audience. 



mous Medal of Honor for service in 
Vietnam. 

There are a total of 1 1 Navy ships 
named for hospital corpsmen. The 
most recently commissioned, USS 
De Wen (FFG-45), is named for 
Ho-spital Corpsman Richard De 
Wert, who received his Medal of 
Honor for Korea service. The USS 
Halyhurion {FFG-40), named for 
Pharmacist's Mate Second Class 
William Halyburton, is expected to 
be commissioned soon. 



U.S- Navv Medicinu 



Features 



Managing an Effective 
Hazardous Substance 
Program at Sea 



HM2 Thomas Zimmerman, USN 



Nearly all operations aboard aircraft 
carriers require the use of hazardous 
substances or exposure to hazards. 
Those monitored on USS Midway are 
Cellulube, water glycol, isocyanates, 
corrosion control chemicals (toluene, 
TMIK, MEK, MIBK, etc.), mercury, 
lead, trichloroethylene, microwave 
radiation, lasers, radiofrequency 
hazards, and JP-5 vapors. 

The problem with these hazards is 
not the identification of the dangers 
involved, but the development of an 
effective management system for the 
exposed personnel. On Midway we 
have a program that works very well 
with moderate worry and upkeep. 

First, we had to determine the 
nature of chemicals and other hazards 
that were present on the ship. This was 
accomplished by a memorandum to 
all departments requesting a list of all 
chemicals used and/ or other hazards 
present in that department. This 
memo was reinforced by person-to- 
person contact in cases where the 
department was not certain what 
hazards existed. 

When the responses were in, the 
substances were reviewed and the ones 

When this article was written, H M2 Zimmer- 
man was assigned to USS Midway as a preven- 
tive medicine technician. He is currently an 
instructor on the staff at the Disease Vector 
Ecology and Control Center. Alameda, CA. 



considered to be the most hazardous 
were noted. 

Research was then done to deter- 
mine the appropriate medical tests for 
each substance. For example, person- 
nel working in the weapons elevators 
are frequently exposed to water 
glycol, commercially known as 
Houghto-Safe. This substance con- 
tains nitrosamines which are sus- 
pected of causing various blood 
dyscrasias, and like any other toxin, 
may have detrimental effects on the 
liver. 

When the results of tests are 
returned they are entered on a special 
SF 600 to which lab chits are superim- 
posed. 1 and a medical officer again 
review the record. Abnormal results 
are rechecked. The medical officer 
performs the physical examination 
portion of the monitoring and follows 
appropriate recommendations for the 
specific hazard as identified in current 
NAVMEDCOM directives for each 
hazard. 

Quarterly requests are made to the 
various divisions involved for names, 
rates, and SSN's of those personnel 
newly reporting and transferring, 
thereby keeping the program current. 

A tickler file is maintained corre- 
sponding to each division and specific 
hazard, with a section devoted to mis- 
cellaneous exposures. This system 



enables the medical department to 
enter the programs into a computer- 
ized data base. Such a tickler file 
requires additional initial start up 
time, but its maintenance once begun 
requires only I day per month. 

Shipboard corpsmen have little 
time to spare and 1 am no exception. 
Nevertheless, the best time to prepare 
for the medical testing period for this 
program is while at sea. Once we enter 
our homeport. the preparation phase 
should be over and the active testing 
should begin. I type all my laboratory 
chits prior to pulling into port as often 
as I can. This saves time during the 
in-port period. 1 then arrange with our 
laboratory to have people come to 
sickbay for blood and urine samples. 
The bloodwork along with the chits 
are sent to the hospital laboratory; the 
urinalyses are done on the ship. For 
those personnel attached to squadrons 
who may be going TAD, the chits are 
prepared in the same manner, and the 
work is coordinated by corpsmen who 
go with the squadrons. Prior to the 
squadron departure, I brief the corps- 
men on what needs to be accom- 
plished while they are away. 

In the case of slit lamp exams for 
laser or radiation exposures and pul- 
monary function tests for isocyanate 
exposure, 1 make these arrangements 
during the first few days in port. 



November-December 1983 



Figure 1 



At Sea • 



In Port-- 



Memo sent to departments requesting a list of 
chemicals used and other hazards encountered. 



Memo to divisions requesting a list of personnel 
exposed to reported chemical or other hazards. 



Research of specific hazards and the medical 
surveillance required for each one. 



Make up the tickler file. 



Prepare special SF 600's. lab chits, make ap- 
pointments (may have to be done in port but can 
be done at sea by message). 



Notify divisions of personnel required to report 
to sickbay to have blood drawn, personnel 
required to go to hospital or dispensary. 



Record results on SF 600, report abnormal 
results to M.O. Repeat testing at appropriate 

intervals. 



An important part of the program is 
rapport, both with the divisions on the 
ship and with the people at the hospi- 
tal. We are very fortunate to have a 
hospital that really supports our 
efforts in the Hazardous Substance 
Programs, the Asbestos Medical Sur- 
veillance Program, and others. The 



relationships that develop between the 
corpsman in charge of the Hazardous 
Substance Program and the various 
divisions must be worked at very hard 
and very often. I sometimes pay ran- 
dom visits to various division officers 
to let them know my concern for their 
men. From these contacts I can tell 



what divisions are going to cooperate 
the most and those that will need some 
work. 

Another important aspect of the 
program is educating the crew. This 
can be accomplished with lectures on 
occupational safety and chemical 
hazards. I have also been able to pass 
the word in a daily column that I write 
in the ship's newspaper called "Ask the 
PMT." This has been well received by 
the crew and has drawn noteworthy 
comments from the ship's executive 
officer. Additional information is con- 
veyed in the industrial hygiene portion 
of the Sanitation and Environmental 
Health Report and also via the 
person-to-person route. 

One other aspect of the Midway 
medical department's structure that 
contributes to the success of this and 
other programs is a corpsman billet at 
Midway "I" Division. The division 
indoctrinates new arrivals and the 
corpsman screens them. This is how 
many personnel are identified as hav- 
ing been exposed to various sub- 
stances or hazards prior to coming 
aboard. Through the work of "1" Divi- 
sion and our program structure, we 
have been able to place over 300 peo- 
ple on the Hazardous Substance Pro- 
gram, with many more in the working. 
Since the program's inception, there 
have been over 250 liver function tests, 
40 slit lamps, 250 CBC's, and 50 pul- 
monary function tests completed. 
Happily, we have had a very small 
amount of serious occupationally- 
related diseases, but that of course 
doesn't lessen the importance of the 
program. 

Figure 1 shows the workings of the 
at-sea and in-port functions and 
represents a seven-point strategy for 
an effective program. 

This system has worked well on 
Midway and I believe that other carri- 
ers can benefit from our success. For 
more information write HMI George 
Wilson, Medical Department, USS 
Midway (CV-4I), FPO San Francisco 
96631. D 



U.S. Navy Medicine 



NAMRU-3's New Cairo Lab 
Open for Business 



LCDR W. Richard Whitaker, USNR-R 



One of the oldest cultures in the world 
now has one of the newest Navy medi- 
cal research laboratories, housed in a 
sandy-colored six-story building that 
rises out of land that once was desert. 
The Kamal-Seal Biomedical Research 
Laboratory, located in the southeast 
of Cairo. Egypt, is the home of U.S. 
Naval Medical Research Unit No. 3 
(NAMRU-3), which has been carrying 
out studies in tropical medicine for 
nearly 40 years. 

The $ 1 million structure, dedicated 
in March 1983, contains over S2 mil- 
lion worth of the most modern equip- 
ment which allows its highly qualified 
personnel to use the latest technology 
in their research. 

NAMRU-3 is divided into nine 
research departments: bacteriology, 
biochemistry, clinical investigation. 
dental research, immunology, medical 



zoology, parasitology, veterinary 
medicine, and virology. All coordi- 
nate their efforts to fulfill the unit's 
mission, that of conducting research 
on the ecology, epidemiology, and 
pathophysiology of infectious diseases 
of military importance prevalent in 
the Middle East. The departments 
also develop, test, and evaluate 
methods for their diagnosis, treat- 
ment, prevention, and control. 

The commanding officer is CAPT 
Craig K. Wallace, MC, an internist 
whose specialty is infectious diseases. 
Since March 1982 he has directed the 
work of 1 1 Navy and 4 Army officers, 
16 enlisted Navy personnel, and 200 
civilian employees, most of them 
Egyptian. Approximately 20 Egyptian 
doctors and medical consultants are 
directly affiliated with the facility, 
while part of the work is being under- 




Dr. Mansour and technician at the high performance liquid chromatography machine. 



taken in cooperation with local re- 
search organizations, hospitals, 
universities, and faculties of medicine, 
the Ministry of Health, and the Egyp- 
tian military. 

'The sophistication of equipment is 
unsurpassed by any single lab in this 
part of the world," CAPT Wallace ex- 
plains, adding that there were only 
three research laboratories in the 
United States with comparable viro- 
logical containment facilities, "The 
new building gives us and the region a 
state-of-the-art capability in basic 
science to deal with all infectious 
agents." 

The new facility permits more effi- 
cient, cost-effective research in pleas- 
ant surroundings; NAMRU-3 had 
outgrown many of its basic labs, some 
of which predated World War II. "It 
will, upon completion," he says, "have 
the ultimate in containment facilities 
in order for us to be able to investigate 
any suspected disease outbreak and 
study infectious agents in complete 
safety." 

That capability is important in ful- 
filling NAMRU-3's primary military 
mission-research relating to the 
health, safety, and performance of 
naval personnel assigned to the Mid- 
dle East and Africa. "Every bit of 
research we conduct here is directed to 
that end," Wallace points out, citing 
the unit's ongoing shipboard study of 
the health of sailors before and after 
shore leave, and research into the 
effects of insect repellant-impregnated 
clothing for military personnel. 

LCDR Whitaker is visiting associate profes- 
sor in mass communications at the American 
University in Cairo und drills at NAMRU-3. 



November-necember 198.1 



/ 




Dr. Skelly and the cytojluorograph distri- 
bution analyzer. 



The research facility also provides 
training for Egyptian scientists and 
medical personnel. "Because of the 
strong academic nature of our scien- 
tific program, we enjoy the respect of 
Egyptians and freely operate locally 
and throughout the region," This 
includes 19 countries of Southwest 
Asia. 

One important program involves 
acute diarrheal diseases in Egypt, 
Somalia, and the Sudan, strategically 
vital areas where Navy and Marine 
Corps personnel might be deployed. 
Tests being conducted include deline- 
ation of the etiological agents, carrier 
studies, management and optimal 
therapeutic regimens, preventive med- 
icine, and antibiotics. Research takes 
advantage of the area's extreme differ- 
ences in populations due to seasonal 
changes and geographic location, 
ranging from Mediterranean to tropi- 
cal climates. The best data, however, is 
being generated from shipboard 
studies of U.S. sailors, according to 
LCDR Louis Bourgeois, MSC, whose 



specialty is bacteriology. "While it is 
valuable to study local populations," 
he explains, "we feel the best data we 
can get is from Americans coming in 
for a long term or on a transient basis." 
Studies have recently been conducted 
aboard USS Eisenhower (CVN-69). 
USS Santa Barbara (AE-28), and 
USS Puget Souml (AD-38), in close 
cooperation with the Navy Environ- 
mental and Pre%'entive Medicine Unit 
7{EPMU-7) in Naples, Italy. 

"With exposure to the Egyptian 
environment," Bourgeois says, "we 
wanted to know what diseases we'd see 
in order to try to determine why peo- 
ple who got sick got sick." In the 
Eisenhower test group, for instance, 
nearly half the sailors who had gone 
on liberty in Alexandria. Cairo, or 
Luxor were ill enough to go on sick 
call. "The thing that has us puzzled at 
this point is that nearly half the cases 
are unexplained. We didn't isolate a 
known etiologic agent." 

Bourgeois refers to the work as "dis- 
ease mapping in this part of the 




CAPT Cahill with analysis plates. 



!0 



U.S. Niivy MedicinL' 



mjE 




A technician works wiih samples on the Gilford 20iS automatic chemistry analyzer. 



world," a feeling that is shared by 
others. "This is a research facility," Dr. 
Regina Skelly. a civilian employee 
whose specialty is immunology, 
proudly says. "If you want to do qual- 
ity research, you want to stay with 
state-of-the-art equipment." She uses 
the terms efficient and most accurate 
to describe such equipment as a cyto- 
tluorograph distribution analyzer, 
one of about 200 in the world and the 
first in Egypt. 

Dr. Moustafa Mansour, a biochem- 
ist, points out a high performance liq- 
uid chromatography machine capable 
of measuring metabolites in blood and 
providing a computer readout show- 
ing peaks and concentrations. The in- 
strument is especially useful for ther- 
apeutic drug monitoring studies. His 
laboratory is also equipped with a 
water liquid chromatograph. The Gil- 
ford 203S automatic chemistry ana- 
lyzer "does all our chemistry," he 
explains, noting that it can reduce a 
technician's task from an hour to 10 




minutes. Less time means more can be 
accomplished. 

'The kind of biochemical analysis 
we perform here," Mansour adds, "can 
only be done on specimens collected 
from patients with diseases that are 
unique to this area of the world, The 
nature of these specimens are such 
that they cannot be transported back 
to the United States for analysis," 
Mansour explains. 

His view is echoed by CAPT 
Richard Cahill, MC. who specializes 
in immunology and hematology. "The 
uniqueness of doing research here is 
that we have the opportunity to study 
a number of patients with diseases 
endemic to this part of the world," 
which results in cooperation with 
many countries and investigators. 
Both doctors describe work being 
done in meningitis, hepatitis, and liver 
fibrosis. "Cases of nonepidemic 
meningitis in the United States and 
Europe are rare," says Mansour. "Not 
here." Likewise, the study of liver 
fibrosis caused by schistosomiasis, 
endemic in Egypt, has application in 
studying the mechanisms involved in 
the pathogenesis of other forms of 
liver disease, such as that caused by 
alcoholism. "The schisto model is 
much better to work with," Cahill 
explains. "We are studying liver fibro- 
sis as a mode! for other forms of 
fibrosis." 

While much of the research will 
benefit people in the underdeveloped 
countries of the world, ultimately, the 
work done at the facility will have mil- 
itary applications for U.S. forces. 
"What we're trying to do is to simplify 
the tests so they can be applicable to 
field operations." says Cahill. "We 
want to develop simple 'dip stick' 
diagnostic tests for diseases which are 
endemic to this area." those which 
could cause serious illness or result in 
'down days' of low performance for a 
person in a combat area. "We want to 
be able to know what the disease is, 
how to treat it, and be able to get a 
recovered patient back out there as 
soon as possible." D 



November-December 198.^ 



So You Want 
To Make Chief 



LCDR Jack L. Peterson, MSC, USN 




The United Slates Navy-Marine 
Corps records of victorious achieve- 
ments on Sand, at sea, and in the air in 
peace and war have won for these ser- 
vices an honored position in our great 
nation. This heritage was passed on to 
us by our leaders, both officer and en- 
listed, whose outstanding examples of 
courage, integrity, and devotion to 
duty are historically significant, They 
accomplished their missions success- 
fully by high caliber leadership and 
personal example. The strength of our 
services depends upon courageous, 
highly motivated, and responsible in- 
dividuals. 

Vaguely familiar ring? This excerpt 
from General Order No. 21. Leader- 
ship in the U.S. Navy and Marine 
Corps, dated and administratively no 
longer in effect, is nonetheless as ger- 
mane today as it has always been. It 
then should not come as a surprise 
that the Navy would choose to select, 
promote, and retain personnel who 
exhibit these fine qualities, particu- 
larly when the selection, promotion, 
and retention concerns the "back- 
bone" of our Navy, the chief petty 
officer. 



LCDK Peterson is Administrative Officer, 
Office of the Medical Officer. Headquarters, 
U.S. Marine Corps, Washington. DC 20380. 



So row want to make "Chief." You 
might ask, "How do you get there 
from here?" or, "How on earth does 
someone manage to glean leadership 
potential from a collection of plasti- 
cized, miniaturized, black and white 
papers?" 

You might look at your career this 
way; 

leadership 

Exposure 

/Awards and Qualifications 

Discipline 

fducation and Training 

^Responsibility 

5ea Duty 

//ealth 

/nvolvement 

/"erformance 

Leadership. There should be state- 
ments in your record attesting to your 
leadership qualities. This will go a 
long way toward convincing a board 
that you have potential for expanding 
roles. Success at one duty station with 
one group of people will not necessar- 
ily provide an adequate indication, 
hence wide exposure is also key. 

Exposure to different people, 
places, cultures, roles, and positional 



demands is important because your 
adaptability and versatility can then 
be measured. You will be able to call 
upon an ever-broadening experience 
base as your career progresses. You, 
your subordinates, and the Navy will 
benefit. In so many words, you need to 
participate in normal assignment rota- 
tion (Sea /Shore), transferring to dif- 
ferent parts of the world (east coast, 
west coast, overseas), seeking different 
duty stations (l&l staff, hospital, 
clinic, naval station, air station, ship's 
company), taking on different jobs 
(section leader, branch head, supply, 
fiscal, laboratory, career counseling). 

Awards and qualifications are 
indicative of effort beyond that which 
is ordinarily exhibited. Earning the 
enlisted Surface Warfare badge fre- 
quently enhances your value to the 
Navy because your perspective has 
expanded. Receipt of a decoration 
(Navy Achievement Medal, Navy 
Commendation Medal, etc.) or selec- 
tion as a sailor of the year provides 
evidence of your willingness to go the 
extra mile. 

Discipline. RADM Arleigh Burke, 
in his study entitled "Discipline in the 
U.S. Navy," gave us some measures of 
discipline. The following can be found 



12 



U.S. Navv Medicine 



in the Bureau of Naval Personnel's 
condensation of that study; 

Besides (he large criterion of combat 
ability, there are many lesser criteria 
which in the aggregate become im- 
portant measures of discipline: (I) A 
dignified prideandself-rcspeci - pride 
in the Navy, in the unii. and in one- 
self; (2) A willingness to work for and 
to make personal sacrifices to the 
group good; (3) A smart appearance — 
a sloppy ship or a slovenly man will be 
so in action; (4) A respect for fellow 
men exemplified in courtesy and con- 
sideration; (5) Optimistic cheerful- 
ness, liveliness, and exhilaration. 

Comments in evaluations to the effect 
that you demonstrate these qualities 
and how you demonstrate them will 
immeasurably aid the Navy in deter- 
mining your standing among peers. 

Education and training are valuable 
supplements to experiences gained 
through exposure. They are valuable 
because you will bring to bear on 
problems new knowledge and means 
of applying that knowledge that may 
well make for better solutions; recall 
the adage about the informed decision 
vice the decision. Education and train- 
ing mean collectively not only civilian 
college courses, but also correspond- 
ence courses, GED equivalency, 
LMET, and local damage control 
courses, for example. Keep your mind 
active. 

Responsibility. We touched on 
responsibility in the paragraphs on 
exposure and discipline. It deserves 
separate attention: possess it, practice 



it, get more of it. Proceed upward 
along two parallels, that of growing in 
your sense of responsibility as a 
person and leader and that of expand- 
ing the scope of resources (men/ wom- 
en, money, materials) for which you 
are responsible. 

Sea Duty. Ours is a maritime ser- 
vice, demanding not just familiariza- 
tion with the seas, but mastery of them 
and all things pertaining thereto. 
There is nothing like the "real thing" 
from which you can truly gain mastery 
of a skill. If we go to war, most of our 
people will go to sea or to Fleet 
Marine Force field units. We won't 
need to get up to speed and lose many 
days or months just acclimating to the 
operational environment. For the 
corpsman, medical practice is not the 
same everywhere. Equipment and 
supplies are austere in the Fleet 
Marine Force and not particularly 
sophisticated on board ships — 
certainly not anywhere near the assets 
one finds in a naval hospital. Your 
NEC precludes such assignment? 
Then get to different duty stations in 
support of different kinds of line units. 
e.g., naval air stations, naval stations, 
naval shipyards. 

Health. Drug and alcohol abuse 
and obesity are among the more pro- 
nounced indications of a lack of con- 
cern for health— your own and that of 
your subordinates. Enough said. 

Involvement. Evidence of your 
active involvement with the commun- 
ity and your unit is important. Few, if 



any, styles of successful leadership call 
for a narrowly defined sense of aware- 
ness and activity. Engaging in plan- 
ning for a ship's party, teaching a 
religious class in a house of worship, 
or camping out with a local Scout 
troop all get you "in touch" with other 
people. We are not a Navy operating 
in a vacuum, using only our means to 
accomplish only our ends. We work 
for and with the people of our Nation. 
Get involved with them. 

Performance. Yes, the last but not 
least. On the negative side, personal 
problems occur in life, some more dev- 
astating or drastic than others; some 
will affect job performance. If this 
happens to you and you need help, ask 
for it! One such incident would not 
necessarily be viewed as a major aber- 
ration and may well be overlooked by 
a board. If you have received a "bad" 
evaluation, devote some thought as to 
why the commanding officer wrote it, 
pick up the pieces, and charge on! On 
the positive side, your diligent, moral 
attention to duty and productive 
effort are your part; the good marks 
will follow. Maintaining is not enough 
though; improve things, innovate. 

Faithful adherence to every rule, 
unswerving dedication to every princi- 
ple, and daily attention to every factor 
will not guarantee selection and pro- 
motion. What these actions will do is 
place you very much in the com- 
petition — that is neither too much nor 
too little to ask of yourself . . . if you 
want to make "Chief." D 



November-December 1983 



13 



Reserve 



Fleet Medicine Revisited 
20 Years After 



CAPT John B, Henry, MC, USNR 



My ACDUTRA (active duty fortrain- 
ing) for 1983 was an exciting expe- 
rience aboard USS Saratoga, a few 
days with the guided missile destroyer 
USS Luce, and a flight on a Sea King 
helicopter for a SAR (Search and 
Rescue) mission. 1 became reac- 
quainted with the fleet and refreshed 
my appreciation for Navy medicine 
afloat. I also had an opportunity to see 
the people who man our ships and 
observe their activities and responsi- 
bilities firsthand. 

My previous sea duty 20 years 
before had introduced me to destroy- 
ers and destroyer escorts. This assign- 



ment aboard Saratoga may have been 
a change in terms of the type of vessel 
but certainly not in the mission of its 
general medical officer. 

Meeting and working with an en- 
joyable group of people in a challeng- 
ing environment proved fascinating. 
Providing care at sea to approxi- 
mately 5,000 men is no small responsi- 
bility. Yet, I found the medical 
personnel to be dedicated and compe- 
tent professionals who took their 
work seriously. 

The medical department had one 
board certified internist, a general 
medical officer with a background of 2 




Dr. Henry aboard USS Luce 



years graduate medical education and, 
when the ship was deployed, a ship's 
surgeon. In addition, there were 40 
corpsmen to handle all the subspecial- 
ties including pharmacy, laboratory, 
sanitation, radiology, the emergency 
and operating rooms, and a 60-bed 
sickbay. The department offered com- 
prehensive and complete medical ser- 
vices such as immunizations, surgery, 
diagnostic assessments, and manage- 
ment. Two corpsmen and a striker 
manned the laboratory and X-ray ser- 
vice. The corpsmen and a physician's 
assistant worked with the medical 
staff while one MSC officer and a 
senior chief handled much of the 
administration. This paperwork was 
about equal to that experienced in a 
university setting from a budget allo- 
cation standpoint. It included finan- 
cial accountability for drugs, 
medication, and equipment. 

Saratoga also had a physician's 
assistant and 1 was most impressed 
with his clinical skills and knowledge. 
The corpsmen too displayed great skill 
and dexterity on their early morning 
sick calls; the emergency room was 
open for the remainder of the day and 
night. 

The most common medical prob- 
lems the department encounters are 
upper respiratory infections, minor 



Dr. Henry, Dean of the Georgetown Univer- 
sity School of Medicine, drills with Medical 
Contingency Response Unit 306, NAVRED- 
COM Region 6, Washington, DC. 



14 



U.S. Navy Medicine 



s-^ 



injuries, and orthopedic complaints 
concerning knees, backs, and feet. 

Psychological/ psychiatric dis- 
orders are also occasionally evident. 
These include immaturity under 
stress, tension, as well as a few person- 
ality disorders. My message to medi- 
cal students in general has always been 
to appreciate the psychological and 
psychiatric manifestations of disease 
whether alone or in association with 
existing organic disease. It is even 
more important at sea, where many 
such disorders may be attributed to 
both youth and stress. 

Eighteen-hour working days are not 
uncommon at sea added to the close 
contact of individuals on board ship. 
However, I noted that living condi- 
tions for both enlisted and officers 
have improved considerably in the last 
20 years. There is greater privacy as 
well as available lounge facilities for 
relaxation. 

Nutrition seemed quite adequate. 
Indeed, the calories were more than 
ample, and my regular visits to mid- 
rats (midnight rations) and the gener- 
ous servings were a pleasant ex- 
perience. A considerable amount of 
energy is consumed working at sea. 
The caloric intake is essential and the 
storage conditions for food undoubt- 
edly prompt the heavy emphasis on 
fats along with an abundance of car- 
bohydrates and ample proteins. With 
reference to hamburgers as "sliders," 
there was a lot of fried food. 

Because a carrier is, in fact, both an 
industrial zone and a living environ- 
ment, the medical department also has 
to monitor noise levels, conditions 
that could lead to heat exhaustion or 
heat stroke, and hazardous substances 
such as fuels, lubricants, and asbestos. 

Sanitation is one of the most impor- 
tant programs in preventive medicine 
aboard any ship and it requires contin- 
ual vigilance. I had an opportunity to 
make a sanitary inspection of the 
wardroom, mess, galleys, reefers, and 
storerooms. The inspection identified 
potential as well as actual hazards. 

The medical depa.rtment also ad- 
ministers urine drug tests by social 
security number every 2 weeks; each 




USS Saratoga 



person is therefore examined approxi- 
mately two to three times annually. 

During drills or in actual emergen- 
cies battle dressing stations are 
manned by a physician or physician's 
assistant and corpsmen depending on 
the size of the area. Saratoga has six 
battle dressing stations covering the 
flight deck and all three levels extend- 
ing the entire length of the ship. Both 
seamen and line officers have acquired 
first aid skills and should an injury 
occur in battle or in the course of day- 
to-day shipboard activity, they are 
prepared to assist their shipmates. The 
medical department trains all enlisted 
and officers to handle the five basic 
wounds, e.g., fracture of an extremity, 
"vcking chest wound, compound frac- 
ture and laceration of the jaw, abdom- 
inal wound with evisceration, and 
traumatic amputation of the hand. 

Finally, I would like to comment on 
the ship's senior medical officer. He is 
normally a flight surgeon and is 
uniquely qualified to perform the 
complex physical examinations 
required by our naval aviators to 
maintain their flight status. He has all 



the sophisticated diagnostic equip- 
ment at his disposal to insure the 
accomplishment of this mission. At 
sea, when the air wing comes aboard, a 
flight surgeon accompanies each 
group and is added to the medical 
department's complement. These phy- 
sicians give special attention to their 
own officers and airmen. 

The few days I spent on the de- 
stroyer were a microcosm of the car- 
rier. The small ship's company 
enabled me to become better ac- 
quainted with the demands and needs 
of the line. There was no apparent 
reduction in responsibility and risk 
assumed by the crew or lack of techno- 
logical sophistication in terms of 
weapons, other support equipment, 
communications, or combat informa- 
tion systems. 

In short, I found my assignment 
very enlightening in terms of my own 
life. It also prompted me to come away 
with the deepest respect and admira- 
tion for my colleagues and for the 
Navy which maintains the security of 
the seas and serves as the front line of 
defense for our Nation. D 



November-December 1983 



15 



Clinical Notes 



Xerostomia 

Diagnosis and Treatment 



COL J.L. Konzelman, DC, USA (Ret.) 
CDR G.T. Terezhalmy, DC, USN 



Managing patients with xerostomia is 
a challenge. Dry mouth is not a spe- 
cific disease entity, but it may be 
secondary to a number of significant 
local and systemic factors. 

Diagnosis 

A reduction in salivary flow has 
been attributed to such factors as 
heavy smoking and alcohol intake, 
aging, altered psychic states, and idi- 
opathic conditions. Specific local fac- 
tors may include the rare congenital 
absence or aplasia of one or more 
major salivary glands or ducts;(/) 
glandular hyperplasia seen in mumps, 
sialolithiasis, and sialadenitis;(2) and 
neoplasias, which usually affect an 
isolated gland (although there may be 
infiltration of multiple glands in 
leukemia and lymphoma). 

Systemic conditions associated with 
xerostomia include diabetes mellitus 
and Sjogren's syndrome, a relatively 
common condition in women between 
the ages of 40 and 60 characterized 
histologically by lymphocytic infiltra- 
tion of the salivary glands.{3.4,) Xero- 
stomia may also be associated with 

Dr. Konzelman is Chairman, Department of 
Oral Medicine, School of Dentistry, Emory 
University, Atlanta, GA 30322. Dr. Terezhalmy 
is Chairman, Oral Diagnosis Department, 
National Naval Dental Center, Bethesda, MD 
20814. 



collagen vascular or connective tissue 
disorders such as systemic lupus 
erythematosus, scleroderma, mixed 
connective tissue disease, and 
polydermatomyositis. 

The most dramatic form of xerosto- 
mia is seen secondary to external irra- 
diation of the head and neck. Implants 
produce more localized, less destruc- 
tive structural changes because effec- 
tive irradiation drops off at the 
periphery. Medications from such 
varied categories as hypnotics, anti- 
spasmodics, decongestants, diuretics, 
antihistamines, amphetamines, tran- 
quilizers, and neoplastic inhibitors 
have all been implicated in xerosto- 
mia. (5) 

Chronic xerostomia may result in 
painful oral soft-tissue problems (Fig- 
ures I and 2), a high incidence of 
rampant caries, and poor tissue 
adaptation to prostheses. Further- 
more, the reduced buffering capacity 
of the saliva leads to a more acid oral 
environment, altering the sensitivity 
of taste buds and precipitating the 
development of hairy tongue (Figure 
3). The increased acidity contributes 
significantly to the alteration of the 
oral ecology, producing predictable, 
dramatic changes in the oral 
microflora. 

The virulence of the resultant carlo- 
pathogenic microorganisms is respon- 



sible forthe logarithmic increase in the 
caries incidence of xerostomic pa- 
tients. This type of caries characteristi- 
cally involves the dentin and 
cementum exposed at the cervical 
areas of teeth (Figure 4) and affects 
cusp tips and incisal edges (Figure 5), 
in contrast to the traditional carious 
penetration of the enamel noted inter- 
proximally and in pits and fissures of 
occlusal surfaces. 

Tooth loss, a predictable sequela of 
advanced carious lesions, presents 
further difficulties for both the patient 
and clinician. Xerostomia contributes 
to decreased retention of tissue-borne 
prostheses, which may in turn contrib- 
ute to the development of traumatic 
ulcerative lesions on already com- 
promised tissue. In irradiated pa- 
tients, such lesions take on added 
significance because they allow for the 
penetration of oral bacteria to deeper 
osseous areas, with a potential for the 
development of markedly morbid 
osteoradionecrosis. 

Treatment 

Saliva substitutes. Systemic man- 
agement directed at the underlying 
cause of xerostomia in most instances 
is within the purview of the physician. 
Saliva substitutes are palliative, and 
they are used primarily to compensate 
for the deprivation of salivary flow. 



16 



U.S. Navy Medicine 




Figure I. Severe xeroslomia secondary so head and neck irradi- 
ation 



Figure 2. Severe xerostomia and mucositis secondary to diuretic 
therapy 



Replacement therapy should be insti- 
tuted with a nontoxic topical agent 
that contains many of the elements of 
normal human saliva and relieves 
intraoral symptoms without signifi- 
cant accumulation of mucosal 
plaques.(6-70) 

For many years clinicians have 
recommended, prepared, and pre- 
scribed a wide variety of wetting 
agents for the xerostomic patient. 
Some have suggested the frequent use 
of water, saline solution, or alkaline- 
saline rinses. (//-/7) Others have 
recommended hard candy, sugarless 
chewing gum, lemon drops,( 18) a wide 
variety of glycerin-based solu- 
tions, (/2, /J, /P-2/) sialagogues, (12, 
19.20-24) and chlorhexidine,(25,2tf) 
all of which provide some degree of 
symptomatic relief. Commercial 
mouthwashes containing alcohol and 
thymol, however, are of little or no 
clinical value. (5) 

In 1974 'S-Gravcnmade et al.(7) re- 
ported on an artificial saliva prepared 
from major bovine salivary glands. 
This mucin-containing product, with 
an apparently extended duration of 
moistening action of mucous mem- 
branes, was reported to exert a protec- 
tive effect on tooth structure. More 
recently. Shannon et al.(9,/0) re- 
ported on the clinical use of an artifi- 
cial saliva that contained mineral 
concentrations comparable to those of 
the human whole saliva, hann and 
Shannon(<S) presented laboratory data 
indicatingthc potential of thisagent to 
induce remineralization. They also 




Figure 3. Hairy tongue 



Ffgure 4. Cervical caries 
xemsiomia 



secondary to 




Figure 5. Caries affecting cusp lips and incisal eiigcs ussociaied with .xeroslomia 



Novemher-Lleccmber iyS3 



17 



presented clinical evidence of dra- 
matic results in irradiated patients and 
in psychiatric patients who expe- 
rienced xerostomia as a side effect of 
major tranquilizers and tricyclic anti- 
depressants. 

Saliva substitutes moisten and lu- 
bricate the oral cavity. The viscosity 
and electrolyte concentrations of the 
substitutes are adjusted to approxi- 
mate whole saliva, and pleasant- 
tasting flavoring is added to most 
preparations. Saliva substitutes may 
be swallowed. 

Rx 

Sodium carboxymethylcellulose, 

0.5 percent aq. sol. (Prepared by your 

pharmacist) 

Disp: 8 oz bottle 

Sig: Rinse as often as needed to 

moisten and lubricate the 

mouth. 

Rx 
Xero-Lube saliva substitute (Scherer 
Laboratories, Inc.) 
Disp: 6 oz bottle 
Sig: Rinse as often as needed to 

moisten and lubricate the 

mouth. 

Rs 

Saliv-aid saliva substitute (Copley 

Pharmaceuticals, Inc.) 

Disp: 2 oz bottle 

Sig: Squeeze 2-4 drops into the 
mouth as often as needed to 
to moisten and lubricate the 
mouth. 

Rx 

Salivart saliva substitute (Westport 

Pharmaceuticals, Inc.) 

Disp: SO ml spray can 

Sig: Spray into the mouth and 

throat for 1-2 seconds as often 
as needed to moisten and lu- 
bricate the mouth. 

It must be emphasized that saliva 
substitutes do not constitute a total 
chemical approach to the problem of 
rampant caries. (P,/0) Daly et al.(27) 
and later Fann and Shannon(5) de- 
scribed a fluoride self-application pro- 



gram for caries prevention in the 
irradiated patient that has shown 
excellent results. At present, a daily 
application of 0.4 percent SnFjget in 
conjunction with a comprehensive 
oral hygiene program is advocated(9- 
11,27). Although these programs were 
implemented initially for the benefit of 
irradiated patients, their applicability 
is readily apparent for many patients 
with xerostomia. 

Rx 

Stannous fluoride gel, 0.4 percent 
(Omni-Gel, Dunhall Pharmaceuti- 
cals, Inc.) 

Disp: 2.3 (6) oz bottle 
Sig: Apply to teeth daily, 5-10 

drops in a moist carrier for 5 

minutes. 

Conclusion 

Symptomatic and supportive care 
of the xerostomic patient should 
include good oral hygiene procedures, 
proper dietary control, and the use of 
saliva substitutes. The substitutes 
should preferably have a pleasant 
taste, contain electrolytes in concen- 
trations normally found in saliva, and 
have the viscosity adjusted with the 
addition of sodium carboxymethyl- 
cellulose. The use of supplemental 
fluoride agents to promote reminerali- 
zation of the enamel is recommended. 
Fluoride delivery systems that provide 
optimal protection are now available. 



References 

1. Gortin RJ, Goldman HM: Thoma's Oral 
/'a/to/og.F. ed6. St. Louis.CV MosbyCo, 1970. 
p964. 

2. Lyons DC: Oral and Facial Signs and 
Symptoms of Systemic Disease. Springfield, 1 L, 
Charles C Thomas, 1968, p 126. 

3. Akin RK, Keller AJ. Walters PJ, Tra- 
pani JS; Sjogren's syndrome. J Oral Surg 
33:22-27, 1975. 

4. Tarpley TM, Anderson LG. White CL: 
Minor salivary gland involvement in Sjogren's 
syndrome. Oral Surg 37:64-73. 1974. 

5. Lyons DC: The dry mouth adverse reac- 
tion syndrome in the geriatric patient. J Oral 
A/frf 27:1 10^1 11, 1972. 

6. Matzker J, Schreiber J: Syntheiischer 
Speiche! zur Therapie der Hyposialian, insbe- 
sondere bei der Radiogenen Sialandenitis. Z 
Laryngol Rhinol 5\:422-i2&. 1972. 



7. 'S-Gravenmade EJ, Roukema PA, Pand- 
ers AK: The effect of mucin-containing artificial 
saliva on severe xerostomia. Int J Oral Surg 
3:435-439, 1974. 

8. Fann WE, Shannon IL: Treatment of dry 
mouth in psychiatric patients. Am J Psychiatrv 
135:251-252, 1978. 

9. Shannon IL, McCrary BR, Starcke EN: 
A saliva substitute for use by xerostomic 
patients undergoing radiotherapy to the head 
and neck. Ow/ 5«rg 44:656-661, 1977. 

10. Shannon IL, Trodahl JN, Starcke EN: 
Remineralization of enamel by a saliva substi- 
tute designed for use by irradiated patients. 
Cancer 4 1:1 746- 1750, 1978. 

11. Bottomley RK, EbersoleJH: Guidehnes 
for dental care when patients receive radiation 
therapy to the head and neck, Oral Surg 22:152- 
256, 1966. 

12. Blozis GG, Robinson JE: Oral tissue 
changes caused by radiation therapy and their 
management. Denl Clin North Am 643-656. 
Nov 1968. 

13. Hinds EC: Dental care and oral hygiene 
before and after treatment. Radiation caries. 
JAMA 215:964-966, 1971. 

14. Billingsley L: Effects from radiation ther- 
apy of oral carcinoma. y/lm//>'jf /lwoc45:305- 
309, 1971. 

15. Carl W, Schaaf NO, Chen TY; Oral care 
of patients irradiated forcancer of the head and 
neck. CaiKer 30:448-453, 1972. 

16. Rubin RL, Doku HC: Therapeutic 
radiology — the modalities and their effect on 
oral tissues. J Am Dent Assoc91J%\-13<i. 1976. 

17. Galil KA: Xerostomia as a post- 
operative complication of vagotomy. J Oral 
A/frf 3 1:82-83. 1976, 

18. Donaldson SS: Nutritional conse- 
quences of radiotherapy. Cancer Res 37:2407- 
2413, 1977. 

19. Bertram U: Xerostomia. Acta Odontol 
5fant/ 25{Suppl 49): 1-1 15, 1967. 

20. Robinson JE: Dental management of the 
oral effects of radiotherapy. J Prosihel Dent 14: 
582-587, 1964. 

21. Dykes P. Harris P, Marston A: Treat- 
ment of dry mouth. Lancet 2:1353, 1960. 

22. Mason DK. Glen Al. The aetiology of 
xerostomia (dry mouth). Dental Magazine of 
Oral Topics 84:235-238, 1967. 

23. Bahn SL: Drug-related dental destruc- 
tion. Oral Surg i}A9-54. 1972. 

24. Faikson HC: Relief of dry mouth. S Afr 
Med J 49:690. 1975. 

25. Coffin F: The management of radiation 
caries. Br J Oral Surg 11:54-59, 1973. 

26. Coffin F; The control of radiation caries. 
Br J Radiol 46:365-368, 1973. 

27. Daly TE, Castro JR. Boone MI.M;Wao- 
agement of Denial Problems in Irradiated Pa- 
tients. M.D. Anderson Hospital and Tumor 
Institute and [Cental Branch (monograph), 
Houston, University of Texas at Houston, 1971, 
pp 7-18. a 



IS 



U.S. Navy Medicine 



Professional 



Perinatal Death: Aiding 
Grief Resolution 



LCDR Charles C. Coddington, MC, USN 



Fetal death is one of the most tragic 
and devastating events that can 
happen to a couple or individual. Even 
the most stable suffer deeply from 
such an event. The longer the preg- 
nancy, the more severe the psychologi- 
cal trauma. These effects can lead to 
problems on an individual basis or 
marital level if not confronted and 
dealt vifith completely. Anxiety about 
child rearing and future pregnancy 
will also result. 

The initial impetus for the support 
group came from several patients who 
expressed a need for help with grief 
resolution over a longer period than 
just routine postpartum care. This 
long-term need was expressed to sev- 
eral sympathetic listeners, and with a 
nucleus of several professions and two 
couples, the group was formed at the 
Naval Hospital, Beaufort, SC. Our 
support of professionals, clergy, and 
individuals of a similar experience 
helps those who have lost infants 
handle and address their grief. 

The motivation for starting such a 
group is simply defining the patient's 
need. In the past, most training pro- 
grams dealt with those, but also with 
the long-term response to loss which 
may last for months and years. Once 
the need in the local area has been 



Dr. Coddington is Chief, Obstetrics and 
Gynecology, Naval Hospital, Beaufort, SC 
29902. 



identified, others with similar goals 
may provide help, support, pam- 
phlets, and information. Some of 
these groups are: 

SHARE (Source of Help in Airing 
and Resolving Experiences) 

St. John's Hospital 
800 East Carpenter 
Springfield, I L 62769 

AMEND 

4324 Berrywich Terrace 

St. Louis, MO 63128 

Bereaved Parents Support Group 
1016 Van Buren 
Madison, Wi 53711 

Compassionate Friends 
Post Office Box 1347 
Oak Brook, IL 60521 

These national organizations are 
available as well as other support 
groups which may be found in larger 
metropolitan areas or around major 
medical centers. 

Approaching each individual who 
has lost a child and addressing their 
specific needs may help them work 
through their grief. Support personnel 
can vary in background from those 
with a prior experience to nurses, 
chaplains, social workers, and physi- 
cians. To insure that each aspect in 



dealing with the loss of a pregnancy is 
covered, it is helpful to develop a flow 
sheet such as Figure I which is used 
effectively in our hospital. With this 
method the information and support- 
ing actions are presented in a very per- 
sonal and complete way to each 
couple or individual. These duties may 
be altered depending on the care pro- 
viders' desire and skills. 

In large centers a check-off sheet 
placed on the chart helps to coordi- 
nate each care provider. An article in 
Contemporary OBjGYN, August 
1982, illustrates such a sheet. Informa- 
tion covered should center around 
providing individual support. The 
physician must be a guiding factor to 
other members of the group as the 
initiator of care after pregnancy loss. 
It may have been the physician's eval- 
uation that determined the infant's 
death; therefore, he/she must become 
involved . The couple should be told of 
the death with sympathy and sensitiv- 
ity. The more direct, the better for 
both physician and the individuals. 
When the death is discovered or con- 
firmed the physician should provide as 
much information as is available. If no 
clear cause can be found this should be 
stated. In the case of an intrauterine 
fetal death the onset of labor can be 
delayed. A patient needs a great deal 
of attention and support. Once labor 
and delivery begins, a caring attitude 
is vital. As more information becomes 



November-December 1983 



19 



available from the delivery or postpar- 
tum evaluation, it should be given to 
the patient as clearly and simply as 
possible. 

After labor and delivery the individ- 
uals should be encouraged to hold the 
infant. Focusing on the normal parts 
is helpful in viewing the infant. Stand- 
ard postpartum care is necessary to 
minimize complications and maxi- 
mize recovery. One should resist the 
urge to discharge the patient as 
quickly as possible allowing more time 
for emotional support. 

Other members of the team are 
essential. Duties may be divided 
according to their talents. One impor- 
tant area is obtaining mementos (foot- 
prints, bracelet, photos) if desired. 
Providing an information package is 
also important and helps to introduce 
the patient and her partner to the sup- 



port group. Members from the group 
may visit the patient in the hospital or 
call her by phone after the hospital 
discharge. Patient Affairs can assist by 
coordinating with the funeral home 
for services and helping to minimize 
administrative problems. In planning 
services and counseling the social 
worker may provide sympathetic lis- 
tening, answer questions about grief, 
teach communication skills, and 
confer with the patient after discharge 
from the hospital as often as needed. 
By getting these and other members of 
the hospital staff involved, the patient 
can receive the best possible suppor- 
tive benefits. 

Knowledge of the grieving process 
is important. Several topics must be 
addressed to help resolve early grief 
reaction. Among these are an intro- 
duction to a caring and supportive 



group. It is crucial that its members 
are comfortable with the painful feel- 
ing of grief in their private lives. A 
normal response to grief may include 
shock and numbness, searching and 
yearning, disorientation and dis- 
organization, reorganization and 
problems of communication, as well 
as guilt. Further discussion of these 
topics may be found in Contemporary 
OBjGYN, August 1982, Share Hand- 
book, Parent Care Booklet, as well as 
other professional sources (see Refer- 
ences). From these resources one may 
develop original written material, or 
with permission, use information 
from the previously mentioned organ- 
izations. Again, the emphasis is on 
providing patient care using team- 
work. This unity is helpful in continu- 
ing a group should a member be 
transferred to a new duty station. 



FIGURE I. Suggested Division of Responsibilities 



Physician 


Chaplain 




Labor & Deliv 


ery Nurse 


Social Worker 


1. Provide support 


1. 


Grief counseling 




1. 


Assist in viewing 


L 


Contact patient 


2. Give information 


2. 


Aid in touch view 






infant 






after delivery 


concerning loss 




of infant 




2. 


Name baby 




2. 


Supportive listening 


3. Autopsy 


3. 


Assist in notification 


3. 


Obtain tangibles — 


3. 


Answer questions 


4. Aid in touch .'view 




of husband, if 


not 




i.e., tootprints. 




on grief 


of infant 




present 






bracelet 


photo 


4. 


Communications 


5. Appropriate medical 


4, 


Followup visit to 


help 


4. 


Empaihetic 


listening 




counseling 


care 




with funeral 










5. 


Daily visit. 


6. Introduce idea of 


5. 


Memorial services 


.if 










if possible 


support group 




desired 










6. 


Contact support 
person: encourage 


Followup in 2 weeks 














7. 


group attendance 
Provide informa- 


1. Determine needs 
















tion package 


2. Referral as necessary 
































Followup in 2 weeks 


Followup in 6 weeks 
















or sooner per 
patient request 


1. Evaluate status of 


















grief and recovery 


















2. Encourage support 


















group participation 





















20 



U.S. Navv Medicine 



Through the course of grief the cou- 
ple may withdraw and initially find it 
difficult to attend a support group 
meeting. The meetings may be 
monthly or more frequent if so desired 
by the group. The duration of attend- 
ance may vary from 2 to 6 months. 
Our meetings vary in size from two 
couples to several couples. It is impor- 
tant to encourage a couple to attend 
the group when they are able to do so. 

Our group has no specific time 
limit, thus it allows for a more com- 
plete discussion of each topic. The 
SHARE group manual is helpful in 
providing structure for the meetings. 
Preparing for each session may vary 
from 1 to 3 hours depending on the 
speaker and topic. Our meetings begin 
with ground rules which encourage 
expression of feelings in a supportive 
atmosphere. There is no effort to limit 
emotion. Each person is encouraged 
to discu.ss everything completely. This 
permits individuals to support one 
another with common experiences. 
During the introduction one may dis- 
cuss why he or she has come to the 
meeting. This leads to support 
responses from the group. A topic is 
then presented on material that has 
been selected by the group or has been 
a source of many questions. At the 
conclusion of the topic there may be 
some business decisions concerning 
the next meeting or other projects that 
apply. These projects are activities 
that help further the group such as 
articles for the newspaper, presenta- 
tion to the community, orcallingindi- 
viduals who may benefit from the 
group. Our meeting usually closes 
with a minute of silence for those 
infants the grieving parents are there 
to remember. 

This format is not fixed, but flexible 
to accommodate the talents and style 
of each facilitator. The leader may be a 
professional such as a social worker, 
chaplain, or physician. These are 
called leader facilitated groups. Inter- 
ested members with experience or 
training in this area may also act as 



leaders. Many workshops are avail- 
able as well as AMEND, an organiza- 
tion devoted to this purpose. Another 
is the therapy-oriented group headed 
by a psychiatrist or psychologist. In 
each of these the central goal is to help 
the couple deal with their grief and 
resolve it normally. 

Our group discusses the medical 
aspects of the death, the autopsy, and 
the neonatal intensive care unit. How 
grief affects husband and wife differ- 
ently is another topic we cover. Recog- 
nition of the difference is important 
for mutual support. 

Teaching how to communicate is 
vital. Partners teach each other this 
skill. This breaks the social isolation 
that surrounds grieving parents and 
helps integrate them back into society. 
We also deal with how to tell children 
about the death. A couple who expe- 
rienced a loss 4 or 5 years ago due to 
Sudden Infant Death Syndrome 
(SIPS) further enriched our program 
and assisted grieving parents by pro- 
viding personal confirmation that one 
does not forget the loss. Discussion of 
a future pregnancy and how it may 
relate to the previous pregnancy is 
important in helping individuals over- 
come anxiety and fear. These themes 
can be developed, modified, or com- 
bined to accommodate speakers. Reli- 
gious faith can also help. 

In summary, there are two impor- 
tant benefits to note for all concerned. 
The first is helping individuals work 
through one of the most tragic losses 
they can face, Secondly, teamwork is 
imperative. 

Our group has served to bring the 
staff together and seems to have 
brought out the best in each member. 
The learning and growth of those who 
participate has been a positive expe- 
rience for the hospital. 

References 

1. AyiLillo A: All our summer memories. 
Cmoil Hoiisckivptiif;, Aug 1979. p 121. 

2. Berezin N: Afier a Loss in Pregimmy. 
Simon and Schuster Publishers, .A Fireside 
Book. I'-JK:. 



3. Berg B: Soihiiig To Cry Ahoui. Seavieu 
Book.s A division of PEI Books Inc. 1981. 
(Recommended for later grief.) 

4. Billingsley J: The child who never 
arrived: a new look at miscarriages. Ijic/iex 
Home Jouniat, Nov 1980. p 32. 

5. Borg S, l.asker J: When Pregmmcy h'aih: 
Familk'i Coping; H'iih Miscarriage, Siilibirth, 
and !nfuM Death. Beacon Press, 1981, 

6. Chez R (Moderauir): Helping patients 
and doctors cope with perinatal death: sympo- 
sium. Contemporary Oli/dYN 20:9K, Aug 
1982. 

7. Conley B: What Happens H'hen Sunie- 
one Dies? Pamphlet available through Thum 
Printing, 116 VV. Prince Street, Elburn, IL 
60119. 

8. Donnelly KK: Raaverini; From the 
Dealh of a Child. Macmillan Publishing Co. 
Fall I9K2. 

9. Fohi C: Slillbirlh: (he silent tragedy. 
Fanitly Circle. Feb 19, 1980. p 66. 

10. Furlong RM, Hobbins JC: Grief in 
perinatal period, OB/G)'A' 6I(4):497. 1983, 

11. Johnson .)M: Nnvhnrn Death: Booklet 
available through Omaha Centering Corpora- 
tion, P.O. Box 3367. Omaha. NE 68102. 

12. Johnson .IM: M'here's .less? Booklet 
available through Omaha Centering Corpora- 
tion. P.O. Box 3367, Omaha, NE 68102. 

13. Kushner H: When bad things happen to 
good people. Redhuok Oct 1981, p 58. 

1 4. Kushner H : When Bad Things Happen to 
Goad People. New York. Shockcn Book>i. 

15. McCall RB: Whenan infanldies. Parent.^ 
Feb 19i<l, p 82. 

16. Moriany I; Mourning the death of an 
mfant: the siblings' slor\. The .lournal of Pas- 
toral Care XXIi(l):22, Mar 1978. 

17. ,Wr. Rogers Neij;hhorhi)i)cl: Talkingwiih 
Young Children .4h<iui Death. Pittsburgh, 
Family Communication Publishers. 1979. 

18. Peppers L. Knapp R: Motherhood and 
Mourning. Praeger Publishers. 1980. S16.<)0 
when purchased from Funeral Directors Asso- 
ciation. 1045 Outer Park Drive. Suite 120. 
Springfield, IL 62704. 

19. Pi/er H. Palinski CO: Coping Hith a 
Miscarriage. The Dial Press, 1980. Available in 
paperback: New York, PLUME Nook. 

20. Price E: Cieltiitg Through the .Nighi. The 
Dial Press. 1982. 

21. Schwiebcrt P. Kirk P: Mhen Hello 
Means Goodhye. Oregon Health Sciences Cen- 
ter. Dcpt. OB CiVN. .1181 Sam Jack.son Park 
Road, Portland. OR 97201. (A guide lor par- 
ents whose child dies at birth or shortly after.) 

22. Shives VA; Coping with a miscarriage. 
Parents .No\ 1980. 

23. TuUen J. Galphin I.. Ramsey S: Parent 
Care. Wake County Medical Center, Wake 
AHEC. Raleigh, NC. 

24. Weisdbery LM: 1 suffered a miscarriage. 
Lady's Circle Mar 1980, p 34. D 



November-December 1983 



21 



Changes in Factor VIII Activity, 
Antigen, and Ristocetin Cofactor Levels 
After Infusion of DDAVP 



LCDR Arnold S. Kirshenbaum, MC, USNR 
LCDR Kaye R. Fichman, MC, USNR 
CAPT Harold M. Koenig, MC, USN 



Factor VIII is a plasma glycoprotein 
thought to exist in vivo as a complex 
of at least two proteins.(/) There are 
three commonly used laboratory mea- 
surements of factor VIII: procoagu- 
lant activity (VIII:C), the clot 
promoting activity that corrects the 
coagulation abnormality in plasma of 
patients with classic hemophilia A; 
antigen level (VIlIR:Ag) which is 
detected in precipitin assays by heter- 
ologous antiserums and is decreased 
in the plasma of patients with von Wil- 
lebrand's disease but normal in 
patients with hemophilia; and risto- 
cetin cofactor activity (VIIIR:RcoO, 
the platelet aggregation promoting 
activity of the factor VIII molecule. A 
level of greater than 50 percent VIIIR: 
Rcof is necessary for the bleeding 
time, ristocetin-induced aggregation 
of platelets, glass bead retention of 
platelets, and adhesion of platelets to 
blood vessel subendothelium to be 
normal. In classical severe vWD, all 
three laboratory measurements of fac- 
tor VIII are proportionally decreased. 
Many variant forms of vWD have 
been described and are characterized 
by discordant reductions in VIIIR: 
Rcof as compared to the levels of 
VlIIR:Ag and ViniC.{2) 

In 1972 the vasoactive peptide 



Dr, Kirshenbaum is with the Department 
of Pediatrics, Naval Clinic. Quanlico, VA. Dr. 
Fichman i.s a pediatric endocrinologist at Naval 
Hospital, Oakland, CA, and Dr. Koenig is 
Director of Medical Affairs at the same facility. 



lysine-vasopressin was found to 
increase the level of VIII;C in normal 
volunteers. Mannucci et al. subse- 
quently reported increases of VIII;C, 
VlIIR:Ag, and V]IIR:Rcof in patients 
with hemophilia and vWD undergo- 
ing surgery after receiving intravenous 
1 -deamino-8-D-arginine vasopressin 
(DDAVP), a synthetic analogue of 8- 
arginine vasopressin.(J) The DDAVP 
effectively promoted hemostasis with- 
out need for exogenous factor VIII in 
most patients. To date, no reports 
demonstrating the efficacy of 
DDAVP have appeared in the U.S. 
literature. 

We studied the effectiveness of 
DDAVP in promoting hemostasis 
during dental extractions in a 12-year- 
old Filipino/ Caucasian male with 
moderately severe vWD who had been 
hospitalized numerous times for 
severe epistaxis. Changes in factor 
VIII related activities were also meas- 
ured after DDAVP infusion in a 16- 
year-old boy with severe classical 
hemophilia and normal control. 
DDAVP administered intravenously 
in a dose of 0.5 meg/ kg just prior to 
dental work in the vWD patient sub- 
stantially increased levels of VIII:C, 
VIIIR: Ag and VIlIR:Rcof, and in the 
normal control. Bleeding was not a 
problem although the vWD subject's 
prolonged bleeding time was not 
reduced to normal levels. Levels of 
VIIlR:Ag and VIUR:Rcof were in- 
creased in the hemophiliac without 
associated changes in VII1:C. 



Patients and Methods 

Subject I was a 12-year-old Filipi- 
no/Caucasian male with an auto- 
somal dominant form of moderately 
severe vWD. He had a prolonged Ivy 
bleeding time and a history of frequent 
epistaxis requiring treatment with 
cryoprecipitate and occasionally red 
cell transfusions. Subject 2 was a 16- 
year-old Caucasian male with severe 
hemophilia A (factor VIII deficiency). 
He would self-administer factor VIH 
concentrate at approximately twice 
weekly intervals to control his hemor- 
rhagic diathesis. Subject 2 had self- 
administered 1500 units of factor VIII 
concentrate for ankle swelling 5 days 
before the study, Subject 3 was a nor- 
mal volunteer. No other medications 
had been used by any of the subjects 
for 1 month before the studies. 

Approval for the use of DDAVP in 
these subjects was obtained from the 
hospital's Committee for the Protec- 
tion of Human Subjects and from the 
Navy Investigational Drug Review 
Board. In addition, individual permis- 
sion was obtained from each of the 
subjects and their parents for the per- 
formance of the study, 

Pre-infusion blood studies were 
obtained and then DDAVP, diluted in 
isotonic saline, was administered 
intravenously over 10 minutes at a 
dose of 0.5 meg per kg. Subject 1 was 
infused just prior to his dental extrac- 
tion. Serial blood samples were 
obtained by venipuncture over the fol- 
lowing 24 hours for coagulation studj^ 



22 



U.S. Navy Medicine 



ies. Nine ml of blood was added to 1 

ml of acid citrate, ph 4.6, in plastic 
tubes and platelet-poor plasma was 
immediately prepared by high speed 
centrifugation for 10 minutes atO°C. 
Ivy bleeding times were determining 
using the Simplate II apparatus (Gen- 
eral Diagnostics). Levels of VIJliC 
were determined using the activated 
partial thromboplastin time one-stage 
assay in use in our hospital clinical 
laboratory. VIIlR:Ag was measured 
by the quantitative immunoelectro- 
phoretic technique of Laurell(4) as 
modified by Zimmerman et al.(5) 
Monospecific antiserum to human 
factor VI 11 for the antigen assay was 
obtained from Dr. Cecil Hougieofthe 
University of California, San Diego 
School of Medicine. The assay for 
VlIlR:Rcof was performed with 
washed gel-filtered normal platelets in 
serially diluted test plasma as de- 
scribed by Weiss et al.(6) 

Results 

Subject 1 with vWD had borderline 
normal VllhCwith decreased levels of 
VIllRiAg, VIllR:Rcof, and a bleed- 
ing time of over 15 minutes. Subject 2 
had severe hemophilia A with less 
than I percent VI1I:C, normal VIIIR; 
Ag, increased VIllR:Rcof, and a 



bleeding lime of 7 minutes. The con- 
trol had normal VIIIiC, VlIIR:Ag, 
and V[IIR:Rcof. 

Subject 1 had only minimal bleed- 
ing during his dental extractions and 
there was no bleeding postoperatively. 
He experienced a sensation of burning 
at the injection site during DDAVP 
infusion. Subject 2 experienced a sen- 
sation of warmth in both arms lasting 
10 minutes after DDAVP infusion. 
There were no problems with fluid re- 
tention, biood pressure, or decreased 
serum osmolality in any of the subjects 
or the control during the course of the 
study. 

Infusion of DDAVP caused a dra- 
matic increase in circulating levels of 
V111:C, VllIR:Ag, and VIIIR:Rcof in 
subject 1 and the control 1 hour post- 
infusion with peak levels between 1 
and 2 hours and return to near base- 
line by 6-12 hours. In subject 2, levels 
of circulating VlllR:Ag and VIIIR: 
Rcof increased similarly but there was 
no change in VI1I:C. Ivy bleeding time 
in subject 1 was shortened from 15 
minutes to 13 minutes 4 hours post- 
infusion and returned to greater than 
15 minutes 24 hours post-infusion. 
Results of coagulation tests pre- and 
post-DDAVP infusion are summar- 
ized in Table 1. 



Discussion 

Intravenous administration of 
DDAVP in oursubject with vWD was 

followed by a 158 percent increase in 
V11I:C, and 120 percent increase in 
VIIIR:Ag, and a 438 percent increase 
in VIIIR:Rcof activities I hour post- 
infusion. Bleeding during and after 
dental extractions was controlled de- 
spite a reduction in Ivy bleeding time 
from greater than 15 minutes to only 
13 minutes 4 hours post-infusion con- 
current with a VIIlR:Rcof of 34 per- 
cent. A further reduction may have 
been realized at I hour post-infusion 
had the bleeding time been measured 
when VIIlR:Rcof was 43 percent. As 
stated above, a VIIIR:Rcof level of 
greater than 50 percent in theory is 
necessary for the bleeding time to be 
normal and could explain this finding. 
It is of interest that other re- 
searchers have obtained similar 
results. Schmitz-Huebner et al. dem- 
onstrated 2- to 5-fold reductions in 
bleeding times determined by hemor- 
rhagometry in 3 patients with vWD. 
(7) Bleeding times pre-DDAVP infu- 
sion in these 3 patients were greater 
than 15 minutes and improved max- 
imally to 10 minutes post-infusion, 
concurrent with levels of VIIIR: Rcof 
less than 50 percent. These patients 



TABLE I. Responses of VIII:C, VIIIR:Ag, and VIIIRiRcof after intravenous 
DDAVP in patients with vWD (1), hemophilia (2), and the Control (C). 



VIlI:Rcof (Percent) 



VUI:C (Percent) 



Pre-infusion 
! hour 
2 hours 
4 hours 
6 hours 
8 hours 
12 hours 
22-24 hours 
Normal 



1 2 


C 


8 195 


45 


43 300 


105 


43 195 


140 


34 185 


170 


25 190 


80 


24 180 


!20 


12.4 - 


105 


11 - 


80 


50 - 


150 



1 2 C 


55 


55 


142 


250 


125 


170 


97 


80 


88 


62 


88 


60 


63 ■ 


60 


63 - 


50 


50 - 


150 



VlIlR:Ag (Percent) 

1 2 C 

10 100 54 
22 250 60 
22 160 82 
18.5 160 66 
13.5 160 43 

11 160 48 
10.5 - 55 
10 - 26 
50 - 150 



November-December 1983 



23 



did not undergo surgery so clinical 
efficacy is unknown. Using DDAVP 
infusion, Mannucci et al. was able to 
control effectively bleeding in a 
patient with vWD undergoing chole- 
cystectomy whose VlllR:Rcof was 
consistently less than 50 percent and 
bleeding time greater than 20 minutes 
before and after DDAVP infusion.(i) 
Mannucci et al. also described 
patients with vWD who had persist- 
ently abnormal bleeding time despite 
increases of VlllR:Rcof to normal 
levels after cryoprecipitate or 
DDAVP infusion.(,S,9) Ludlam et al. 
described patients with vWD who had 
levels of VII]R:Rcof less than 50 per- 
cent and normal bleeding times. (70) 
These observations cannot be ex- 
plained by differences in methods of 
performing bleeding times. Perhaps 
our factor VIII model of two proteins 
is oversimplified, and genetic varia- 
tions currently unknown allow for 
hemostasis despite subnormal VIIIR: 
Rcof levels. 

To determine whether DDAVP will 
be efficacious, we recommend each 
patient be infused with a test dose of 
0.5 meg per kg DDAVP before sched- 
uled surgery and bleeding time meas- 
ured. Reductions in bleeding times to 
normal suggest efficacy. Patients with 
prolonged bleeding times may expe- 
rience bleeding during or postopera- 
tively and require cryoprecipitate to 
maintain hemostasis. 

Infusion of DDAVP into subject 2 
increased levels of VIIIR:Ag 150 per- 
cent and VIIIR:Rcof 54 percent I 
hour post-infusion over pre-infusion 
levels. There was no rise in VIII :C 
activity. Patients with severe hemo- 
philia (VIII:C 1 percent) have also 
been shown by others not to have an 
increase in VI1I:C after administra- 
tion of DDAVP. (i) These results are 
not unexpected since patients with 
severe hemophilia A produce factor 
VIII that lacks VIILC. 

Nilsson et al. demonstrated that 
plasma prepared from normal blood 
donors given intravenous DDAVP 
before phlebotomy and later infused 
into patients with vWD caused bleed- 
ing times to become normal.(y/,/2) 



Analysis of this plasma revealed 1 .5 to 
3-fold increases in levels of VI1I:C, 
VIIIR:Ag, and VIIIR:Rcof compared 
to plasma obtained from the same 
donors not receiving DDAVP before 
phlebotomy. Comparable increases 
(in VI1I:C, VIIIR:Ag, and VIIIR: 
RcoO were obtained in our control. 
These findings suggest VII1:C and 
VIIIR:Rcof prepared from plasma 
post-DDA VP infusion are functional. 
The preparation of cryoprecipitate 
with 1 to 3 times as much VI!I:C as 
conventional preparations would 
reduce exposure of patients to hepati- 
tis and transfusion reactions. 

Generally, the infusion of 1 unit of 
VIII:C per eg of body weight will raise 
the level of circulating VIII:C by 2 
percent. In subject I. who weighed 40 
kg, the DDAVP infusion was equiva- 
lent to administration of approxi- 
mately 1750 units of VII1:C. On the 
average I bag of cryoprecipitate pre- 
pared from 1 unit of whole blood con- 
tains 80-100 units of VII1:C, thus 18 to 
22 bags of cryoprecipitate would have 
to have been transfused into subject I 
to achieve a similar increment in circu- 
lating VI11:C levels. One bag of cryo- 
precipitate costs our blood bank $30. 
The cost for this cryoprecipitate 
would have been about $600. In this 
subject DDAVP eliminated the 
requirement for cryoprecipitate trans- 
fusion and significantly reduced the 
risk of hepatitis exposure, transfusion 
reactions, and hospital costs. 

In summary, DDAVP increases lev- 
els of VIII:C, VlIIR:Ag, and VIIIR: 
Rcof in some patients with vWD and 
mild hemophilia A. Effective hemo- 
stasis with DDAVP during surgery 
and postoperatively appears possible 
in selected patients with vWD. It is 
recommended that patients be infused 
with DDAVP before surgery with 
bleeding time determinations. Bleed- 
ing time reductions to normal will help 
select candidates likely to benefit from 
those possibly requiring cryoprecipi- 
tate and further study. It also appears 
that cryoprecipitate with 1 .5 to 3 times 
the level of VIILC present in conven- 
tional cryoprecipitate preparations 
can be obtained from normal blood 



donors pretreated with DDAVP. Ad- 
ditional clinical trials are needed to 
substantiate these findings. 

References 

1. Factor VIII, NIH Conference. Ann 
Inlern A/frf 86:598-616, 1977. 

2. Gralnick HR, Sultan Y, Coder BS; von 
WiUebrand's disease-combined qualitative and 
quantilive abnormalities. N Engl J Med 296- 
1024-1030, 1977. 

3. Mannucci PM, Ruggeri ZM, Pareti Fl, 
Capitanio A; l-Deamino-8-D-Arginine vaso- 
pressin: A new pharmacological approach to 
the management of hemophilia and von WiUe- 
brand's disease. LMncel 1:869-872, 1977. 

4. Laurell CB: Quantitative estimation of 
proteins by electrophoresis in agarose gel con- 
taining antibodies. Anal Biochem 15:45-52, 
1966. 

5. Zimmerman TS, Ratnoff OD, Powell 
AE: Immunologic differentiation of classic 
hemophilia (factor Vlll deficiency) and von 
WiUebrand's disease: With observation on com- 
bined deficiencies of antihemophilic factor and 
proacceierin (factor V) and on an acquired cir- 
culating anticoagulant against antihemophilic 
factor. J Clin Invest 50:244-254, 1971. 

6. Weiss HJ, Moyer LW. Rickles FR, 
Varma A, Rogers J: Quantitative assay of a 
plasma factor deficient in von WiUebrand's dis- 
ease thai is necessary for platelet aggregation: 
Relationship to factor VIII procoagulant activ- 
ity and antigen content, ./ Clin Invesi 52:27(1S- 
2716, 1973, 

7. Schmitz-Huebner U, Balleisen L, Arends 
P, Pollman H, Sutor AH: DDAVP-induced 
changes of factor Vlll-related activities and 
bleeding time in patients with von WiUebrand's 
syndrome. Hemostasis 9:204-213, 1980. 

8. Mannucci PM, Canciani MT, Rota L, 
Donovan BS: Responseof factor VIII von Wii- 
lebrand factor to DDAVP in healthy subjects 
and patients with hemophilia A and von WiUe- 
brand's disease. Br J Haematol 47:282-293, 
1981. 

9. Mannucci PM, Pareti Fl, Holmberg L, 
Nilsson IM. Ruggeri IM: Studies on the pro- 
longed bleeding time in von WiUebrand's dis- 
ease. J 1Mb Clin Met/ 88:662-671, 1976. 

10. Ludlam CA, Peak IR. Allen N, Davies 
BL, Furlong RA, Bloom AL: Factor VIII and 
fibrinolytic response to deamino-8-D-arginine 
vasopressin in normal subjects and dissociate 
response in some patients with hemophilia and 
von WiUebrand's disease, Br J Haematol 
45:499-511, 1980. 

11. Nilsson IM, Mikaelsson M. Vilhardt H, 
Walter H: DDAVP Factor VII! concentration 
and its properties in vivo and in vitro. Thromh 
Res 15:263-271, 1979. 

12. Nilsson IM, Walter H, Mikaelsson M, 
Vilhardt H: FactorVIII concentration prepared 
from DDAVP stimulated blood donor plasma. 
Scand J Haematol 22:42-46, 1979. d 



24 



U.S. Navy Medicine 



Notes & Announcements 



In Memoriam 

Navy Medical Department victims of Beirut terrorist 
bombing, 23 Oct 1983: 

HMC George W. Piercy 
HM2 William B. Foster, Jr. 
H1VI2 James Ellis Faulk 
HMl Ronny K. Bates 
HM2 George N. McVicker 
HM3 Joseph P. Milano 
HM3 David E. Worley 
LT John R. Hudson, MC 
HIVI2 Michael H. Johnson 
HN Bryan L. Earle 
HM2 Marion E. Kees 
HN J.R. Kane 
HN William D. Elliot 
HM3 Diomedes 1, Quirante 

F. Edward Hebert School of Medicine 

A recent act of Congress named the School of Medicine 
of the Uniformed Services University of the Health Sci- 
ences (USUHS) as the F. Edward Hubert School of 
Medicine. 

This act of Congress reflects its acknowledgment of 
Representative Hubert's 25-year effort to secure the crea- 
tion of USUHS. As early as 1947 Mr. Hebert was urging 
the Armed Services Committee to "set up the school for 
the individual who wants to become a doctor, being wilhng 
to exchange his or her talents over a longer period of years 
so that the Government could get its investment back." 
Twenty-five years later the Congress enacted and the Pres- 
ident signed the Uniformed Services Health Professions 
Revitalization Act of 1972, which created USUHS as a 
source of career-oriented medical officers with significant 
specialty training in military medical subjects. 

Because of other programs developed by the University, 
USUHS will continue to be known as the Uniformed 
Services University of the Health Sciences. However, the 
University's School of Medicine will be known as the F. 
Edward Hebert School of Medicine. 



Top Medical Reservist 

RADM Joseph H. Miller, MC, USNR, has been 

appointed Deputy Director of Naval Medicine for Reserve 
Affairs jointly by the Director of Naval Medicine (Sur- 
geon General) and the Chief of Naval Reserve. 

Miller, who is vice chairman of the Department of 
Neurosurgery at the University of Tennessee Center for 



the Health Sciences in Memphis, TN, assumed his new 
position in June 1983. As Deputy Surgeon General for 
Reserve Affairs, he advises the Navy Surgeon General and 
the Chief of Naval Reserve on all matters relating to the 
Navy's Reserve medical force. 

The job is primarily concerned with enhancingthe over- 
all readiness of the Medical Department and the Navy/ 
Marine Corps team by developing more viable Reserve 
programs and relevantly trained reservists. 

In addition to his position at the University of Tennes- 
see, RADM Miller is a senior member of the Neurosurgi- 
cal Group of Memphis. 



Occupational Health Workshop 

The Navy Environmental Health Center will sponsor 
the 26th Navy Occupational and Environmental Health 
Workshop 7-13 April 1984 at the Pavilion Tower Hotel, 
Virginia Beach, VA. 

Occupational and preventive medicine personnel are 
encouraged to attend this workshop. There is no registra- 
tion fee. 

For additional information contact Dianne Best, Navy 
Environmental Health Center, Naval Station, Norfolk, 
VA 2351 1. Telephone: FTS 954-4657, Commercial (804) 
444-4657. 



AOMA Publications List Available 

The American Occupational Medical Association 
(AOMA), the nation's largest society of occupational phy- 
sicians, announces the publication of an up-to-date cata- 
logue listing more than 200 articles and reports about the 
health of workers. The Publications List, available from 
the Association at no charge, contains information on a 
wide variety of vital occupational health topics including: 

• Toxicology and the effects of chemical exposures, 

• Administration of occupational health programs, 

• Medical Information Systems, 

• Recognition of job-related illnesses, and 

• Health risks related to selected occupations. 

Articles are reprinted from the internationally-recog- 
nized Journal of Occupational Medicine, AOMA's official 
monthly publication. Most articles are priced at SO. 75 
each. Complete information for ordering reprints is 
included in the List. 

To obtain copies of the AOMA Publications List, send 
name and address to AOMA Publications List, American 
Occupational Medical Association, 2340 S. Arlington 
Heights Road, Arlington Heights, IL 60005. 



November-December !983 



25 



Ships Named for Hospital Corpsmen 



Several readers have brought to our attention that corpsman, five honor World War II corpsmen, two 
USS De Wert {U.S. Navy Medicine, May-June are named for corpsmen who served during the 
1983) was not the second vessel named for a Navy Korean War, and three honor corpsmen who gave 
hospital corpsman, and that USS Williams was not their lives in Vietnam. Seven received Medals of 
the first. In fact, 1 1 ships have been named for hospi- Honor, four were awarded the Navy Cross; one of 
tal corpsmen since 1919. One honors a World War I the latter also received a Silver Star. 


Litchfield {DD-336) 




Pharmacist's Mate 3rd Class 
John R. Litchfield, USN 


KIA France 
5 Sept 1918 


Daniel A. Joy (DE-585) 




Pharmacist's Mate 2nd Class 
Daniel A. Joy, USNR 


KIA Guadalcanal 
5 Oct 1942 


Thaddeus Parker (DE-369) 


Pharmacist's Mate 2nd Class 
Thaddeus Parker 


KIA New Georgia 
20 July 1943 


Z.es/er(DE-1022) 




Hospital Apprentice 2nd Class 
Fred F. Lester, USNR 


KIA Okinawa 

8 June 1945 - 


Francis Hammond (DE-1067) 


Hospilalman 

Francis C, Hammond, USN 


KIA Sanae-Dong, Korea 
26 March 1953 


Valdez (DE-1096) 




Hospital Corpsman 3rd Class 
Phil 1. Valdez, USN 


KIA Danang, South Vietnam 
29 Jan 1967 


Caron {DD-970) 




Hospital Corpsman 3rd Class 
Wayne M, Caron, USN 


KIA Quang Nam, South Vietnam 
28 July 1968 


David R. Ray(UT>-91\) 




Hospital Corpsman 2nd Class 
David R. Ray, USN 


KIA An Hoa, Quang Nam 
Province, South Vietnam 
19 March 1969 


Jack Williams (FFG-24) 




Pharmacist's Mate 3rd Class 
Jack Williams, USNR 


KIA Iwo Jima 
3 March 1945 


Halyburton (FFG-40) 




Pharmacist's Mate 2nd Class 
William D. Halyburton, Jr., USNR 


KIA Okinawa 
10 May 1945 


DeWert {¥¥QA5) 




Hospitalman 

Richard De Wert, USNR 


KIA Wonju, Korea 
5 April 1951 



26 



U.S. Navy Medicine 



INDEX 

Vol. 74, Nos. 1-6, January-December 1983 



ACDUTRA 

fleet medicine revisited 20 years after 

6:14 
Naval Reserve 4:21 
student entitlements 1:36 

AFIP (see Armed Forces Institute of 
Pathology) 

Ah!, DR.. CAPT, DC, necrotizing ulcera- 
tive gingivitis 1:30 

Air Force, U.S. 

denial technician training 2:18, 4:9 

American Occupational Medical Associa- 
tion (AOMA) publications list avail- 
able 6:25 

Antarctica 1:18 

Antrim, D.D., CAPT, DC, treatment of 
traumatic dental injuries by non- 
dental personnel 3:18 

AOMA (see American Occupational 
Medical Association) 

Armed Forces Health Professions Schol- 
arship Program (AFHPSP), travel 
eligibility 1:36 

Armed Forces Institute of Pathology 
(AFIP), U.S. V. Willie J. Smith 5:15 

Armstrong, S.R., CDR, NC, (Ret.), a 
new approach to corpsman training 
1:26 

Assessing patients' health status with the 
Navy Dental Health Questionnaire 
2:24 

Assignment on ice !:I8 

Audiovisual materials available 2:32, 3:29 

Augmentation for MSC officers 1:37 



BEELEY, J.M., Surgeon Commander, 
Royal Navy, hospital ship SS Uganda 
at war in the South Atlantic 4:14 
Beirut, Lebanon 

blizzard rescue 3:1 

Mobile Medical Augmentation Readi- 
ness Team (MMART) on station with 
Marines 1:1 

Navy Medical Department victims of 
terrorist bombing, list of 6:25 

NOTE: Figures indicate the issue and page in 
Volume 74 of U.S. Navy Medicine. For exam- 
ple, 6:14 shows the article may be found In issue 
No. 6, page 14. 



Benzathine penicillin, prophylactic 
administration to Navy and Marine 
Corps recruits 2:19 
Bethesda, MD, naval hospital earns 

accreditation 3:28 
Birth 
perinatal death, aiding grief resolution 
6:19 
Birth disorder 

neurofibromatosis, help for 5:28 
Blizzard rescue in Lebanon 3: 1 
Brown, S.W., HMCM, Force Master 

Chief, retires 6:2 
BUM ED (Bureau of Medicine & Surgery) 
history (series) 
where medical college left off: the 
U.S. Naval Medical School and 
Naval Hospital 1902-1917 1:9 
"the greatest physician"— Ben- 
jamin Rush 1:17 
controversy and transition 1917- 
1942 2:8 



CAIRO, Egypt 

NAMRU-3's new lab open for business 
6:9 

Casualties, combat, stress of caring for 1:4 

Casualty care correspondence course 3:28 

Catalog of Navy Training Courses (CAN- 
TRAC)2:I8 

Changes in factor VIM activity, antigen, 
and ristocetin cofactor levels after 
infusion of DDAVP 6:22 

Changes of command, NAVMEDCOM 
4:6 

Chernow, B., LCDR, MC, USNR, effec- 
tive use of vasodilators in pulmonary 
hypertension secondary to recurrent 
thromboembolic disease 1:33 

Chief petty officer 6:12 

Children 

weight program 5:11 

Cholera in Truk, a major epidemic 5:20 

Civic action in Honduras 4:3 

CNO's policy on illicit drugs 5:28 

Coalinga, CA, Navy responds to earth- 
quake 5:2 

Coddington, C.C, LCDR, MC, perinatal 
death: aiding grief resolution 6:19 

Combat casualties, stress of caring for 1:4 



Computer-assisted refraction for the fleet 
4:24 

Contingency and occupational policy 
statements for dental technicians 5:27 

Cope, G., LT, MC, LSNR, blizzard rescue 
in Lebanon 3:1 

Corpsman training, a new approach 1:26 

Correspondence courses (see Training) 

Cote, C.W., CAPT, NC, first male nurse 
selected for captain 3:13 

Courses (see Training) 

Court-martial 

U.S. V. Willie J. Smith. AFIP and 
criminal cases 5:15 

Crabbe, J.R.. LCDR, MSC, prophylactic 
administration of benzathine penicil- 
lin to Navy and Marine Corps 
recruits 2:19 

Criminal cases, AFIP 5:15 

Critical care medicine consensus state- 
ment available 5:28 

Crocker, C.A., HMCM (Ret.), interviews 
CDR Weiner on Antarctica 1:18 

Cunningham, G., LCDR, MC, from 
SEAL to surgeon 4:5 



DENTAL technicians 

CANTRAC 2:18 

contingency and occupational policy 
statements 5:27 

Medical Enlisted Commissioning Pro- 
gram, officer status in Nurse Corps 
2:18,4:9 

NAVMEDCOM point of contact 4:9 

new NEC- dental hygiene technician 
2:18 

projected billets increase 2:18 

references for training 5:27 

requesting technical and specialty train- 
ing 5:27 

retention 2:18 

training with U.S. Air Force 2:18, 4:9 
Dentistry 

Dental Health Questionnaire, assessing 
patients' health status 2:24 

glossodynia, diagnosis and treatment 
5:18 

necrotizing ulcerative gingivitis 1:30 

traumatic dental injuries, treatment by 
nondental personnel 3:18 



November-December 1983 



27 



xerostomia, diagnosis and treatmenl 
6:16 

DeiVeri, USS, named for hospital corps- 
man 3:4 

Drake, M., HM2, Navy researchers com- 
bat disease 2: ( 

Drug evaluations aboard fleet units 4:22 

Drugs, illicit, CNO's policy 5:28 

EARTHQUAKE in Coalinga, CA. Navy 
responds 5:2 

Education (see also Training) 
corpsman, a new approach to training 

1:26 
medical education facts 1:36 

Ellis, H.M.. LT, MC, USNR, prophylactic 
administration of benzathine penicil- 
lin to Navy and Marine Corps re- 
cruits 2:19 

Evans, F., CDR, civic action in Honduras 
4:3 

FACILITIES, Navy medical 

Bethesda naval hospital earns accredita- 
tion 3:28 
Lemoore naval hospital responds to 

Coalinga earthquake 5:2 
NAMRU-2 combats disease 2:1 
NAMRU-3's new Cairo lab open for 

business 6:9 
Naval Medical Research and Develop- 
ment Command (NMRDC) 5:4 

Factor VIII activity, antigen, and risto- 
cetin cofactor levels after infusion of 
DDAVP, changes in 6:22 

F. Edward Hebert School of Medicine 
named for USUHS School of Medi- 
cine 6:25 

Fetal death, aiding grief resolution 6:19 

Fichman, K.R., LCDR, MC, USNR, 
changes in factor VIII activity, anti- 
gen, and ristocetin cofactor levels 
after infusion of DDAVP 6:22 

Field medical service correspondence 
course 3:29 

Fleet medicine revisited 20 years after 6: 14 

Frank, J.L. Ill, CDR, preventive medicine 
aboard USS Scoti 2:3 

Fraud, waste, and abuse 6:1 

GENETIC birth disorder 

neurofibromatosis, help for 5:28 
Georgetown University School of Medi- 
cine, dean's welcome remarks to class 
of 1986 3:11 
Gingivitis, necrotizing ulcerative 1:30 
Glossodynia, diagnosis and treatment 5:18 
Gottesman. A.M., Ed. D., a new approach 

to corpsman training 1:26 
Green, L.V., Jr., HMCM, new Force 
Master Chief 6:3 



HAZARDOUS substances, managing an 

effective program at sea 6:7 
Heat illness 3:25 
Hebert, F. Edward, School of Medicine 

6:25 
Hemophilia A 
changes in factor VIII activity, antigen, 
and ristocetin cofactor levels after 
infusion of DDAVP 6:22 
Henry. J.B., CAPT, MC, USNR 
fleet medicine revisited 20 years after 

6:14 
welcome remarks to Georgetown Uni- 
versity School of Medicine class of 
1986 3:11 
Herman, J.K. 

Home of BUM ED (series) 
where medical college left off: the 
U.S. Naval Medical School and 
Naval Hospital 1902-1917 1:9 
"the greatest physician" — Benjamin 

Rush 1:17 
controversy and transition 1917-1942 
2:8 
pharmacy techs at sea 4:10 
History 

BUM ED (series) 
where medical college left off: the 
U.S. Naval Medical School and 
Naval Hospital 1902-1917 1:9 
"the greatest physician"— Benjamin 

Rush 1:17 
controversy and transition 1917-1942 
2:8 
Surgeon Pieadwell 3:5 
Hogan. B.W., RADM, MC (Ret.), in 

memoriam 3:28 
Honduras, civic action in 4:3 
Hospital Corps, Navy 
Brown, S.W., HMCM, Force Master 

Chief, retires 6:2 
CANTRAC 2:18 
Green, L.V., Jr., HMCM, new Force 

Master Chief 6:3 
Medical Enlisted Commissioning Pro- 
gram, officer status in Nurse Corps 
2:18, 4:9 
memorial for corpsmen 4:28 
NAVMEDCOM point of contact 4:9 
NEC Manual change 2:18 
new approach to training 1:26 
new NEC's approved for a Selective 

Reenlistment Bonus 2:18 
projected billets increase 2:18 
references for training 5:27 
requesting technical and specialty train- 
ing 5:27 
retention 2:18 

ships named for corpsmen 6:26 
Hospitals (see Facilities, Navy medical) 
Hughes, P., LT. NC, USNR. effective use 



of vasodilators in pulmonary hyper- 
tension secondary to recurrent 
thromboembolic disease 1:33 
Hutton, K.L., LT. MSC, Navy responds 
to Coalinga earthquake 5:2 

INFANTS 
perinatal death, aiding grief resolution 
6:19 
Infusion of DDAVP, changes in factor 
VIII activity, antigen, and ristocetin 
cofactor levels 6:22 
In memoriam 

Hogan. B.W., RADM, MC (Ret.) 3:28 
Kenney, E.G.. RADM, MC (Ret.) 2:33 
McDonald. L.P., CAPT, MC, USNR- 

R 5:28 
Navy Medical Department victims of 
Beirut terrorist bombing, list of 6:25 
Palton, W.K., LT, MSC (Ret.) 2:33 
Interviews 

Mace, L., H M 1 , pharmacy technician at 

sea 4:10 
Weiner, W.J., CDR, MSC, clinical psy- 
chologist, experience in Antarctica 
1:18 
Izzett, T., HM3. story of SEAL to surgeon 
4:5 

JOCHUM, G., JOl 

LHA means largest hospital afloat 6:4 
Tuscaloosa's "doe" 3:2 

KENNEY. E.C, RADM, MC (Ret), in 
memoriam 2:33 

Kirshenbaum, A.S., LCDR, MC, USNR. 
changes in factor VIII activity, anti- 
gen, and ristocetin cofactor levels 
after infusion of DDAVP 6:22 

Knox, W.B., LT, USNR, drug evaluations 
aboard fleet units 4:22 

Koenig, H.M., CAPT, MC, USN, changes 
in factor VIII activity, antigen, and 
ristocetin cofactor levels after infu- 
sion of DDAVP 6:22 

Konzelman. J.L., COL, DC, USA (Ret.), 
xerostomia: diagnosis and treatment 
6:16 

Kretchmer, R.S., LCDR, MSC, drug 
evaluations aboard fleet units 4:22 

LAKE, C.R., M.D., Ph.D., effective use 
of vasodilators in pulmonary hyper- 
tension secondary to recurrent 
thromboembolic disease 1:33 

Lamar, S.R., LCDR, MSC, NMRDC: 
Headquarters for research and devel- 
opment 5:4 

Lebanon, Beirut 
blizzard rescue 3:1 
Mobile Medical Augmentation Readi- 



es 



U.S. Navy Medicine 



ness Team (MMART) on station 
with Marines 1:1 
Navy Medical Department victims of 
terrorist bombing, list of 6:25 
LHA (largest hospital afloat) 6:4 
Lungs 
pulmonary hypertension secondary to 
recurrent thromboembolic disease, 
effective use of vasodilators 1:33 

McDERMOTT, W.M., Jr., RADM, MC 
Commander, Naval Medical Com- 

niand 4:7 
fraud, waste, and abuse 6:1 
getting down to business 4: 1 
quality of care: a perception 5: 1 
TRIMIS (Tri-Service Medical Infor- 
mation System) 4:8 
McDonald, L.P., CAPT, MC, USNR-R, 
in memoriam 5:28 

MACE, L., HM 1, pharmacy technician at 
sea 4:10 

Managing an effective hazardous sub- 
stance program at sea 6:7 

Medal of Honor Hall dedicated 6:6 

Medical Department, Navy, victims of 
Beirut terrorist bombing, list of 6:25 

Medical education facts 1:36 

Medical Service Corps, Navy, augmenta- 
tion for officers 1:37 

Miller. J.H., RADM, MC, USNR, ap- 
pointed Deputy Director for Reserve 
Affairs 6:25 

MM ART (Mobile Medical Augmentation 
Readiness Team) supports Lebanon 
deployment 1:1 

Monuments 

Benjamin Rush 1:17 

hospital corpsmen memorial 4:28 

Mouth 
glossodynia, diagnosis and treatment 

5:18 ' 
xerostomia, diagnosis and treatment 
6:16 

NAVAL Medical Command (NAVMED- 
COM), Washington. DC 
changes of command 4:6 
Medal of Honor Hail dedicated 6:6 
point of contact for HM'sand DT's4:9 
Naval Medical Research and Develop- 
ment Command (NMRDC), Bethes- 
da. MD 5:4 
Naval Medical Research Units. U.S. 
NAMRU-2 combats disease 2:1 
NAMRU-3's new Cairo lab open for 
business 6:9 
Naval School of Health Sciences 
audiovisual materials available 2:32. 
3:29 



Necrotizing ulcerative gingivitis (NUG) 

1:30 
Neurofibromatosis, help for 5:28 
NMRDC (see Naval Medical Research 

and Development Command) 
NSHS (see Naval School of Health Sci- 
ences) 
NUG (necrotizing ulcerative gingivitis) 

1:30 
Nurse Corps, Navy 

celebrates 75th anniversary 3:14 

first male nurse selected for captain: 

C.W. Cote 3:13 
stress of caring for combat casualties 1:4 

OBSTETRICS and gynecology 

perinatal death, aiding grief resolution 

6:19 
Occupational health publications list 

available 6:25 
Occupational policy statements for dental 

technicians 5:27 
Optometry 

computer-assisted refraction for the 

neei 4:24 

PATTON, W.K., LT, MSC (Ret.), in 

memoriam 2:33 

Pediatric weight watchers 5:1 1 

Pelleu, G.B., Jr., Ph.D., assessing pa- 
tients' health status with the Navy 
Dental Health Questionnaire 2:24 

Penicillin, benzathine, prophylactic 
administration to Navy and Marine 
Corps recruits 2:19 

Perinatal death, aiding grief resolution 
6:19 

Periodontics 

necrotizing ulcerative gingivitis 1:30 

Peterson, J.L., LCDR, MSC, so you want 
to make chief 6:12 

Pharmacy techs at sea 4:10 

Pilley, M.P., LT,NC, USNR. effective use 
of vasodilators in pulmonary hyper- 
tension secondary to recurrent 
thromboembolic disease 1:33 

Pleadwell, F.L, 3:5 

Pollock. L.A., H Ml, prophylactic admin- 
istration of benzathine penicillin to 
Navy and Marine Corps recruits 2: 19 

Poppell. G.H.. LCDR, MSC. cholera in 
Truk: a major epidemic 5:20 

Preventive medicine 
aboard USS Scoit 2:3 
hazardous substances, managing an 
effective program at sea 6:7 

Prophylactic administration of benzathine 
penicillin to Navy and Marine Corps 
recruits 2:19 

Publications list available, occupational 
health 6:25 



Pulmonary hypertension secondary to re- 
current thromboembolic disease, 
effective use of vasodilators in 1:33 

QUESTIONNAIRE, Navy Dental Health 

2:24 

RAHE, R.H., CAPT, MC, cholera in 

Truk: a major epidemic 5:20 
Ramey, T.G., CDR, MC, USNR, effective 
use of vasodilators in pulmonary 
hypertension secondary to recurrent 
thromboembolic disease 1:33 
Recruits, Navy and Marine Corps, pro- 
phylactic administration of benza- 
thine penicillin 2:19 
Research, Navy 
NAMRU-2 combats disease 2:1 
NAMRU-3's new Cairo lab open for 

business 6:9 
NMRDC: headquarters for research 
and development 5:4 
Reserve, Naval 

fleet medicine revisited 20 years after 

6:14 
Miller, J.H., RADM, MC, USNR. ap- 
pointed Deputy Director for Re- 
serve Affairs 6:25 
new training programs 4:2! 
Rush (Benjamin) monument 1:17 
Ryder, J.. HM3. Tuscalnnxa'f. "Hoc" 3:2 

SAGAN, W.. CAPT, MSC. USNR-R, 
computer-assisted refraction for the 
fleet 4:24 
Saltman, L.E., Ph.D., a new approach to 

corpsman training 1:26 
SEAL to surgeon 4:5 
Seaton, L.H., VADM, MC, 29th Surgeon 

General 4:6 
Shea, F.T,, RADM, NC, stress of caring 

for combat casualties 1:4 
Ships 

drug evaluations aboard fleet units 4:22 
named for hospital corpsmen 6:26 
SS Uganda at war in the South Allan- 
tic 4:14 
USS De Wert; named for hospital 

corpsman 3:4 
USS Enierprise. computer-assisted 

refraction for the fleet 4:24 
USS Midway, managing an effective 
hazardous substance program at 
sea 6:7 
USS Saratoga, fleet medicine revisited 

20 years after 6: 14 
USS Scott, preventive medicine pro- 
gram 2:3 
USS Tarawa. LHA means largest hospi- 
tal afloat 6:4 
USS Tuscaloosa's "doc" 3:2 



November-December 198.3 



* us. GOVERNMENT PRINTING OFFICE: 19S3— 381-323/304 



29 



U.S. NAVAL PUBLICATIONS and FORMS CENTER 
ATTN: CODE 306 
5801 Tabor Avenue 
Philadelphia, PA 19120 
Official Business 



POSTAGE AND FEES PAID 

DEPARTMENT OF THE NAVY 

DoD-316 

SECOND CLASS 




Sims, J.R., HMC, prophylactic adminis- 
tration of benzathine penicillin to 
Navy and Marine Corps recruits 2:19 

Smith, J.W., LCDR, MC, cholera in 
Truk: a major epidemic 5:20 

Spencer, J.D., CDR, MC, AFIPand crim- 
inal cases 5:15 

Steele, K., LCDR, NC, heat illness 3:25 

Strapp, M.A„ LCDR, NC, pediatric 
weight watchers 5:1 1 

Stress of caring for combat casualties 1:4 

Students 

ACDUTRA entitlements 1:36 
AFHPSP. travel eligibility 1:36 
CNO's policy on illicit drugs 5:28 

Surber, B., LT, MC, USNR, heat illness 
3:23 

TAYBOS, G.M., CDR, DC 

assessing patients' health status with 
the Navy Dental Health Question- 
naire 2:24 

glossodynia: diagnosis and treatment 
5:18 
Teenagers 

weight program 5:11 
Terezhalmy, G.T., CDR, DC 

assessing patients' health status with the 
Navy Dental Health Questionnaire 
2:24 

glossodynia: diagnosis and treatment 
5:18 

xerostomia: diagnosis and treatment 
6:16 



Thromboembolic disease, recurrent 1:33 
Tongue 

glossodynia, diagnosis and treatment 
5:18 
Training 
correspondence courses 
casualty care 3:28 
field medical service 3:29 
dental technicians 2:18, 4:9, 5:27 
hospital corpsmen L26, 2:18, 5:27 
medical deep sea diving technician 5:27 
nuclear submarine medicine technicians 

5:27 
Reserve, Naval, new programs 4:21 
special operations technician 5:27 
Traumatic dental injuries, treatment by 

nondental personnel 3:18 
Travel 

AFHPSP, student and member eligibil- 
ity 1:36 
TRIM IS (Tri-Service Medical Informa- 
tion System) 4:8 
Truk Stale, cholera epidemic 5:20 

UGANDA, SS, hospital ship at war in the 

South Atlantic 4:14 
Uniformed Services University of the 
Health Sciences (USUHS) 
applications being accepted for School 

of Medicine 5: 17 
School of Medicine renamed F. Edward 
Hubert School of Medicine 6:25 
U.S. v. Willie J. Smith. AFIPand criminal 
cases 5:15 



VASODILATORS in pulmonary hyper- 
tension secondary to recurrent 
thromboembolic disease, effective use 
nf 1:33 
Vietnam 
combat casualties, stress of caring for 
1:4 
Vision 
computer-assisted refraction for the 
fleet 4:24 
von Willebrand's disease 

changes in factor VllI activity, antigen, 
and ristocetin cofactor levels after 
infusion of DDAVP 6:22 

WEIGHT watchers, pediatric 5:11 
Weiner, W.J., CDR, M.SC, experience in 

Antarctica 1:18 
Whitaker, W.R., LCDR, USNR-R, 

NAMRU-3's new Cairo lab open for 

business 6:9 
Wilbur, D.A., LT, MSC, the inimitable 

surgeon Pleadwell 3:5 

XEROSTOMIA, diagnosis and treatment 
6:16 

ZALOGA, G.P., LCDR, MC, USNR, 

effective use of vasodilators in pul- 
monary hypertension secondary to 
recurrent thromboembolic disease 
1:33 
Zimmerman, T., HM2, managingan effec- 
tive hazardous program at sea 6:7 



U.S. NAVY MEDICINE